BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIP WATER RESOURCES CONTROL BOARD FORM `A': a,' •. UNDERGROUND STORAGE TANK PROGRAM £ ;gym SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ T NEW PERMIT 3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM p INTERIM PERMIT 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE S 00 ry I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) CD FACILITY/SITE NAM CARE OF ADDRESS INFORMATION II N 4 L✓l o rGL —`anSon ADDRESS / l NEAREST CROSS STREET 1 ✓110 I'M u1 0 PAFTNERSHP STATEAGENCY �� ❑ CO0",10N 0 LOCAL0 AGENCY 0 FEDERAL CITU NAME 11INONIDUAL 0 COUNTRAGENCY STATE ZIP ODE SITE PHONE#.WITH AREA CODE _77 CL CA N537(o go ") -S oS� TYPE OF BUSINESS: p DIS IBUTOR F-14 PROCESSOR ✓Box if INDIAN EPA ID # ESEI GASSTATION 3 FARM S OTHEfl TRUSTYLANDS ATION or ❑ - Moi AT THHISIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE ft WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME 'I CARE OF ADDRESS INFORMATION _`11 ori LCtLA(a Arc MAILING or ST EET ADORES ✓Box to iodicaM 0 PARTNERSHIP ❑ STATE-AGENCY �, U a 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL ElCOUNTY-AGENCY CITY NAME STAT I ZIP ODE PHONE 4,WITH AREA CODE S3? a-OQc 3S r III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME w ^ CARE OF ADDRESS INFORMATION 1 •V MAILING o,STREETADDRESS ✓Bax to,,dicate 0 PARTNERSHIP 0 STATEAGENCY❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTN LEGAL NOTIFICATION AND BILLING: I. ❑ If. 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 IIS JURISDICTION P AGENCY k FACILITY ID IF R of TANKS at SITE r V 2 � O CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LLOCATIONCODE CENSUS TRACT X SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED r�-'�. YES NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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 ONL FORMA(3-2-68) DATA PROCESSING COPY