BILLING PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNI9 WATER RESOURCES CONTRARIOARD FORM 'A'• UNDERGROUND STORAGE TANK PROGRAM SITE I FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE h ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE � I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) CCD G FACILITY/ E ME CARE OF ADDJWS INFORMATION ADDRESS NEA TCROSS STREET ✓�Bofm iMicale ❑ PARTNERSHIP ❑ STATE AGENCY '(/ ,,. ^- , Pf CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY �j2.( ] T(�/Yj�- w •— ❑ INDIVIDUAL Cl COUNTYAGENCY CITY NAM STATE ZIP—CODESITE PHO# #.WITH AREA CODE Z`OC;k , CA .5-LOA 20 - 7 "gl7o TYPE OF BUSINESS: ❑ 2 DISTRIBUTOfl ❑ 4 CESSOfl I/Box if INDIAN EPA ID a It of TANK'a /� RESERVATION or AT THIS SITE DV ❑ I GAS STATION ❑3 FARM 5 OTHE TRUST LANDS ❑ CACi40O/' S EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) p NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS�N'�ME(LAST,FIRST) PHj,1fJ WITH AREA CODE �� Rr? ql b S A L NIGHT AME(LA T,FIRST) PHONE a WITH AREA CODE NIGHT AME(LAST,FIRST) PypN1E a WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BEV^COMPLETED) S/A NAMES CARE OF ADDRESS INFORMATION MAILIN or�EET ADDRESS ✓ Io indicate ❑ PARTNERSHIP ❑ STATEAGENCY ( j( CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY O' t3 (A 0 2d ❑ INDIVIDUAL Cl COUNTYAGENCY CITY NA* STAT& ZIP CODE HOIN�,'WI HAREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME `/ CARE OF ADDRESS INFORMATION MAILING or STREET DRESS ✓Box to odicire El PARTNERSHIP STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION k AGENCYA, FACILITY ID N N of TANKS at SITE ro 10 �- sI 1�I C) 0v CURRENT LOCAL A ENCY FACILITY IDN APPRQVED BY NA PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE P RMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DIS T CODE BUSINESS PLAN FILED DATE FILED iC YES NO CHECK# PERMIT AMOUNT C! SURCHARGE AMOUNT FEE CODE RECEIPT# BY: 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. FORM A(3-2-58) DATA PROCESSING COPY