BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNL., FORM 'A#: WATER RESOURCES CONTR SITE UNDERGROUND Ct-40ARD FACILITY/SITE, INFORMATION and/orTA PERMIT GRAM COMPLETE THIS FORM FOR EACH FACILITY/SITE i mfr APPLICATION P. . Z MARK ONLY � 1 NEW pERMl7 ONE ITEM 3 RENEWAL PERMIT `'4.oe�r 1 O ❑2 INTERIM PERMIT 5 CHANGE OF INFORMATION I. FACILITY/SITE INF El 4 AMENDED PERMIT 7 PERMANENTLY CLOSED SITE INFORMATION& ❑B TEMPORARY SITE CLOSURE 1-a FACILITY/SITENAME^ ADDRESS— (MUST BE SQ V (� /'. /y1 COMPLETED) W i ADDRESS �y7n�\�~` ,�G CARE OF ADDRESS INFORMATION 00 — N-/ Lo . NEAREST CROSS STREET V CITY NAME ✓Bm k+ k O,.f� ❑ GGINOlUI N ❑ Lq II-AGD ❑ ST,1TEgSRN (-JL C... ❑ IND100, ❑ 1�L,IGENGY ❑ RppgL.A'ENLY TYPE OF BUSINESS. STATE 21P�0CE�� ❑ CgINTY-,IGFNLY 2 DISTRIBUTOR CA Y/ SITE PHONE p,WITH AREA CODE ❑ 1 GAS STATION 4 pRCCESSOR ✓BoxiIINDIAN EPA Ip# _I 3 FARM E]5 OTHER RESEgVA710N or ❑ - EMERGENCYCONTACT PERSONTRUST LANDS (PRIMARY) AT THISof SLAST,FIRST) DAYS:EMNAME(LAST,ERGENCY CONTA Y) BITE DAYS: NAME( PHONE#WITH AREA CODE CT PERSON(SECONDAg FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION & ADDRESS — PHONENwITH AREA CODE NAME (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION MAILING 01 STREET ADDRESS ./Box to indicate ❑ PARTNERSHIP CITY NAME ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE p,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME ~ CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓BuxtOinrlioale ❑ pgRTNERSHIP ❑ STATE-AGENCY CITY NAME ❑ NDIRVIDUALIo" ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ COUNTY-AGENCY 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 COUN� JURISDICTION AGENCY# FACILITY ID# 33 1Iu�� #of TANKS at SITE o Eaioo � CURRENT LOCAL AGENCY FACILITY IDNAPPROVED BY NAME I�.�nr EK;_;L5 P 0 NONEN WRH AREA CODE PERMIT NUMBER ^PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ATION CENSUS TRACCTT 0 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 9 D-2s ou 01 YES NO [:] ''a( ' qQ 1 CHECK N RMLT AMOUNT SURCHARGE AMOUNT ,FEE CODE RECEIPT# BY: I THIS FORM MUST BE ACCOMPANIED BY AT L r OR MORE TANK PERMIT FORM 'B'APPLICATION(" —S IS A CHANGE OF SITE INFORMATION ONLY. JFORM A(3-2-88) DATA PROCESSING COPY A .