BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORA WATER RESOURCES CONTIRBOARD FORM `A': - UNDERGROUND STORAGE TANK PROGRAM ;" a SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION l o COMPLETE THIS FORM FOR EACH CILITY/SITE F7MARK,ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERM TLCY C D SITEEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O D N I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) CT1 FACILITY/SITE NA ,— / �v CARE OF ADDRESS INFORMATION ADDRESS LAJ�W,N/A/�EI U NEAREST CROSS ST EET EW ole Cl PARTNERSHIP ❑ STATE AGENCY ATION ❑ LOCAL AGENCY ❑ FEDERAL AG AL ❑ CODNIY-AGENCYCITY NAME �^ STATE ZIP DESITE PHONE N WITH A EA CODE J CA SZOO TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑4PMESSOR ✓Boz if INDIAN EPA ID it ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER RESERVATION or ❑ - #of TANK's TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: AME(LAST,FIRST) W V✓� PHONE k WITH AREA CODEAVS: NAME(LAST,FIRST) PHONE N WITH AREA CODE ox Z�KNIGHTS: NAME(LAST FIRSTTJPHONE N WITH AREA CODE NIGHTS NAME(LAST,FIRST) PHONE#WITH AREA CODE IL PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME �n _ CARE OFA ESS INFORMATION / MAILING or STREET ADDRESSp ✓ to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY 7/'71 OR V /� `,. PORATION El ElFEDERAL-AGENCY�J �/1 L/ INDIVIDUAL ❑ COUNTY-AGENCY CITU NAME STATEZIP CODE PHONE k,l UpREA CODE (//r�'r� Q s 7p-/N III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME `' CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS) ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE ft 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.7-:1 -111 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 Al AGENCY# FACILITY ID# #of TANKS at SITE CURRENT LOCAL AGENC((Y�fP/1CILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION O CENSUS TRA/�T# a SUPERVISOR-DI TgICT CODE BUSINESS PLAN FILED DATE FLl �YYES NOCHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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. RM A(3-2-SS) a 5 DATA PROCESSING COPY