BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN'll WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r l ' o COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMA Y CLOSED SITE I"A' ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 IV I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) C" N FACILITY/SITE ME CAREOFAD RESSINFORMATION Coll 0 N ADDRESS ` NE ST CROSS STREET ✓ ozlol�H¢ele ❑ PARTNERSHIP ❑ UATEAGENLY y3 a 5 w CORPORATION ❑ LOCAL ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA TYPE BUSINESS. F-12 DISTRI8UTOR ❑ 4 PROCESSOR Box,t INDIAN EPA 10 IfRESER A /� WAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTTYLANDS ATION o ❑ `A LOO Al ZOb / AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DA NAME(LAST;FIRST) PHONE I WITH AREA CODE DAY NAV (LAST,FIRST) PHONE p ITH AREA CODE �72,7N AV NIGHTS: N�M1E( ST,FIRST) PHONE#WITH AREA CODE NIG NAME(LAST.FIRST) PHONE N ITH AREA CODE /( -A d II. PROPERTY OWNER INFORMATION'& ADDRESS — (MUST BE COMPLETED) NAME CARE OF AD KESS INFORMATION 5 © I I N MAILING ar STREET DRESS ✓gek l0 indcate Cl PARTNERSHIP ElSTATE-AGENCY B'CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY w 1 ❑ INDIVIDUAL ❑ COUNTY-AGENCY CIN NAM STA ZIP CODE PHONE p,WITH AREA CODE o a a- 2i2z� III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS v ✓Dox to odica]e ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,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. ❑ 11. 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 k JURISDICTION M AGENCY R FACILITY ID At #of TANKS at SITE M = = 10O 1 1 1715-131 d lo C) CURRENT LOCAL AGENCY FACILITY ID 0 APPROVED BY NAZ PHONE N WITH AREA CODE t-CO/V S Z 8 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINE77; DATE ]LED 3 CeJ1� 3 (6^`(J` ey d NO o0 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEECODE PT• 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. FORMA(3-2-88) DATA PROCESSING COPY