BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORRA WATER RESOURCES CONTROL BOARD A FORM `A': UNDERGROUND STORAGE TANK PROGRAM "o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE C#<IFOa NSP ,O MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITEz N ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE �✓ ) I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) N FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION I� Y 0e P PeD ADDRESS NEAREST CROSS STREET ✓BUFOYtlWx ❑ PARTNERSHIP ❑ B'TATEAGENCY l 1 O I \I El 11 11LDCAL AGENCY ❑ FEDERAL-AGENCY Vel? ❑ ADMOUAL ❑ CWNMAGENcy CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE TYPE OF BUSINESS: EPA ID # 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if[RESERVATION o \ ❑ I GAS STATION ❑ 3 FARM ❑ 5OTHER If of TANK's TRUSTYLANDS or ❑ AT THIS SITE wl EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY Cl FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl 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: L ❑ N. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE [1511 1 1 114 IWE I I I I I CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CC IP PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATI C E CENSUS TRAC.LA SUPERVISOR-DISTRACT CODE BUSINESS PLAN FILED DATE FILED L/61C�3 + Vl/ YES NO CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If B THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFOL FORM A13-2-BB) • DATA PROCESSING COPY