BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �� SITE CfACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F ILITY/SITE ''°""0 MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURES .0 I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) W FACILITYISITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET Y.Io nd ale a PMTN RSHIP Cl STATS AGENCY LW-CMWIIDN a LOCK-AGENCY ❑ FEDERALAGENCY /carte 4u/-C, a INDIVIDUAL ❑ GDUNN AGINCY CITY NAME STATE ZIP CODE $ITE PHONE N,WITH AREA CODE fc.� CA off+y .. yr.. -s-Y 3-7— TYPE OF a SINESS: ❑2 DISTRIBUTOR ❑4 PROCEMA ✓Box it INDIAN EPA ID N RESEGAS STATION ❑3 FARM ❑ 5 OTHER TRUSTVLANDS or ❑ L /.� `I , AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME{LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME may `- CARE OF ADDRESS INFORMATION Q wr.12 G: S MAILING or STREET ADDRESS +/130K to indieale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL.-AGENCY ❑ INDIVIDUAL_ ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ K le indicate ❑ PARTNERSHIP ❑ STATE-AGENCY IT CORPORATION ❑ LOCAL-AGENCY FEDERAL-AGENCY ❑ INDIVIDUAL El COUNTY-AGENCY CITY NAMESTATE ZiP CODE PHONE N,WITH AREA CODE �7 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. 7;(4,k APPLIGANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY! JURISDICTION N AGENCY M FACILITY ID N N of TANKS at SITE 101 (,-JF/- 1 7_1=,S__ r) I o= CURRENT LOCAL AGENCY FACILITY 10 S APPROVED BY NAME PHONE 11 WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACTS SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 0 -3 is L'_1 -.'�3 YES ❑ NO S/f c) CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT S BY: THIS FORA DUST BE ACCOMPANIED BY AT LEAST(1)ORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS S A CHANGE OF SITE INFORMATION ONLY.,\N OFIM A(3-2-88) I W ' DATA PROCESSING COPY