BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN WATER RESOURCES CONTROARD FORM A: UNDERGROUND STORAGE TANK PROGRAM z �o SlrT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION l o C COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Q fJ N i4 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CD FACILI /SITE NAME CARE OF ADDRESS INFORMATION ADDRESS N RST CROSS STRE T ✓CORPORoubmATIOmle 0 LDCALAGEN 0 STATFEDERAAGD ////,,tt ❑ CONPOMiION 0 PARTNA&P 0 PBIERAGENUQ' If t? D F 0 INOMDNAL ❑ CO Ntt ABEN Y CIN NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE S- � CA a 3 - 0 3 TYPE OF BUSINESS'. ❑ 2DISTRIBUTOR ❑•4 P19CESSOR -/Box 0INDIAN EPA IDN Aof TANK'RESEs ❑ 1 GASSTATION ❑3FARM OTHER TRUSTYLANDS of ❑ 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 Coz ;to4 3 /;30 NIGHTS: NAME(LAST,FIRST) PHO #WITH AREA CODE NIGHTS: NAME(LAST FIRST) PHONE p WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 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 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III.L] 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 COUNT TY/M JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE CURRENT'S LO LOCAL FACILITY � �P�D BY NAME � PHONE N©A�CODE VPERMITNUMBERjjERMIT APPROVAL DATE PERMIT EXPIRATION DATE SUPERVISOR-DISTRICT CODE BUSINESSYESN❑ED ,+O ❑ DATE FILED SURCHARGE AMOUNT FEE CODE RECEIPT# (/G- BY[Q. THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) • DATA PROCESSING COPY