BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNI?C WATER RESOURCES CONTRLvrBOARD FORMA': UNDERGROUND STORAGE TANK PROGRAM SITE TM FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY V1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 ONE ITEM ❑ 2 INTERIM PERMIT ❑ / AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) G FACIL� INFORMATION C704 MAILING v STREET AD MAILINGar STREETADDRESS AA Q �T -T • V� sJ I /.. ! O ✓9oA{ xto in0icate ❑ PARTNERSHIP CORPORATION D LOCAL.AGENCY D INDIVIDUAL D COUNTY -AGENCY ❑ STATE -AGENCY D FEDERAL -AGENCY ADDRESS N EST CR SS STREET ✓ iUrle ❑ PAATNAWIP ❑ STATE AGENLY �a ' /1 ��J/ ZIP CODE PHONE N. WITH AREA CODE LOGL.Afs TILY RllEML#GENGY oV I �- NDMDMTNIN ❑ NDVINPl ❑ �I11ITY-MiMGY CITY N E STATEZI CAy� • Fay/ SITE PHONE N, ITH AREA ODE PERMIt EXPIRATION 15ATE CA ) 3 7 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ d POCESSOR ✓ Box It INDIAN EPA ID N TANK's CENSUS TRACT If RESERVATION of ❑ BUSINESS FLAN FILED DATE ILED of ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS YES NO� AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) D&S: NAME (LAST, FIRST) PHO E N WITH AREA CODE DAYS: NAME (LAST, FIRST) ONE N WITH AREA CODE �� /�J'l.,.� WCN/'i��fY'ry Q 7 A /`rP W i NIGHTS: NAME (LAST. FIRST) . PHONE N WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PONE N WITH AREA CODE Z I S II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME dh� /jq CARE F ADDRESS INFORMATION MAILING v STREET AD MAILINGar STREETADDRESS AA Q �T -T • V� sJ I /.. ! O ✓9oA{ xto in0icate ❑ PARTNERSHIP CORPORATION D LOCAL.AGENCY D INDIVIDUAL D COUNTY -AGENCY ❑ STATE -AGENCY D FEDERAL -AGENCY CITY NAME Loi i STATE ZIP CODE s2 HON yo e? N, WITH AREA CODE v 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME y -DRESS CARE OF ADDRESS INFORMATION MAILING v STREET AD ✓ Box to indicate D PARTNERSHIP D STATE -AGENCY D CORPORATION D LOCAL -AGENCY D FEDERAL -AGENCY V 7 y 7 ( D INDIVIDUAL D COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE N. WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS i CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. El 111. ❑ I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY M FACILITY IDR N of TANKS N SITE V 7 y 7 ( CURRENT LOCAL AGENCY FACILITY ID APPROVED BY E PNONEk WITH AREA CODE or Y/-/�// PE MIT NUMBER PERMI APPR AL DATE PERMIt EXPIRATION 15ATE LOCATION CODE CENSUS TRACT If PERVISOR-DISTRICT CODE BUSINESS FLAN FILED DATE ILED YES NO� CMEC N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN 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 (3-2-88) DATA PROCESSING COPY II A 0 N