BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNO WATER RESOURCES CONTE BOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F ILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY LOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bwbodca ❑ PAWNEFMIP ❑ VATEAGENCY ❑ Ron ❑ LOCAL AGENCY [3 RDERALAGENCY MDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE li.WITH AREA CODE CA a0 qIS TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # X of TANK', E] 1 GAS STATION E] 3 FARM ❑ 5 OTHER TRUSTYATION LANDS or F—] ATTHIS 817E EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE Or ITH AREA CODEDAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE J _3 3�_ w,11 a NIGHTS'. NAM (LAST,FIRST) PHONE 110iVITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE It WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME v2 CARE OF ADDRESS INFORMATION MAILIN STREET ADDRESS ✓Box to indicate 11 PARTNERSHIP ClSTATE-AGENCY ❑ CORPORATION El ❑ FEDERAL-AGENCY A ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE M.WITH AREA CODE CA �a 2 Ill. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME ^ CARE OF ADDRESS INFORMATION MAILING or STREET AVbRESS V I ✓Box(.indicate ❑ PARTNERSHIP Cl STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY M FACILITY ID R I1 o1 TANKS N SITE D ai CURRENT LOCAL A7OENCY F CILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE ^/ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LLOCATIONCODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILEDYES NOPERMIT AMOUN SURCHARGE AMOUNT FEE CODE RECEIPT 11 Y: I ) THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY D