BILLING PRE 2019 - Laserfiche WebLink

Home Browse Search

�p"fRY+�.Vwer�--�^^,nr•-^-,.r+.rrzrz.osi,.w... ter..R-1,. ..; N,,y v- .. - �.., � STATE OF CALIFORNI0 WATER RESOURCES CONTR OARD FORM A: UNDERGROUND STORAGE TANK PROGRAM e z $� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m< 10 COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY ❑ I NEWPERMIT F-13 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PER CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE / ,jI r I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) w tD FACILITY/SITE NAME CARE OF ADDRESS INFORMATION C iH � NEAREST CROSS TREEOR D A D STATE ADORE CORPORATION 11 LOCk-AGENCY ❑ FD)ER4L-AGENCY O INDMWAL ❑ fAUNiY-AGFNLY CITU NAME —717 + v, — STATE ZIP CODE/ O S ,;O�E N,WITH AREA COD IV TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 P SSOR ✓Boz#INDIAN EPA ID N �,n /1�� #of TTAN✓✓K'7s RESERVATION or ❑ ' l/Y "kms AT THIS SITE l ❑ I GAS STATION ❑3 FARM OTHER TRUST IANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NjiE(LAST,rJR$ (poONEN AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE Ul' II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY ❑ INDIVIDUAL D 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. ❑ II. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE m F-070TZ= 1010101n CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACTI SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED / l 3 1// 1 `a YES NO lD CHECK# / PERMIT AMOUNT L/ SURCHARGE AMOUNT FEE CODE RECEIPT M 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 0 LY. FORM A(3-2-88) DATA PROCESSING COPY I