BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA, WATER RESOURCES CONTROMOARD FORM IA': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F ITY/SITE MARK ONLY ❑ 1 NEW PERMIT E] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE tV ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE r I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) J FACILITY/SITE NAME CARE OF ADDRESS INFORMATION � ¢S nc ADDRESS ;EPA ST CROSS STREET ✓aft roracae 0 PARTNERSHIP ❑ STATEAGFNC/ __7 (/G h 6 0 CORPDPATION ❑ LOCAL AGENCY ❑ FEDER/L-AGENLY ❑ INDMDUAL Cl WUNWAGENC/ CITY NAME ZIP CODE SITE PHONE A.WITH AREA CODE A - TYPEOFBUSINESS: ❑ 2DISTRIBUTOfl ❑ 4 ESSOR ✓Box if INDIAN N ❑ I GAS STATION ❑ 3 FARM E:g5 OTHER TRUSTYLANDS or ❑ AT THIS SITE O EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(RST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE nc ' S e Zr,1r�8�3-aa 3 NIGHTS: NAME(LP T, IRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME / CARE OF ADDRESS INFORMATION YC.� _TUsC li MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY F S ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toin0icate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH A A 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. 11. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION N AGENCY N FACILITY ID a Al of TANKS at SITE D 1 o 1 i �/ s D 1 o 1 c _D CURRENT LOCAL AGENCY FACILITY IO N APPROVED BY NAME PHONE N WITH AREA CODE CAL k_5`,F Y. PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 01/ Cp 3 1:5�0 3 8�_(m YES ❑ NG ❑ 3At CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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-SS) I// I z— ` ` DATA PROCESSING COPY ,� N