BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNO WATER RESOURCESCONTRO4PBOARD o: FORM AA': z ; UNDERGROUND STORAGE TANK PROGRAM ;mss SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION "F� COMPLETE THIS FORM FOR EACH FACILITY/SITE .Cy(IlOP N•P. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYC ITE ONE ITEM El INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE S o >� I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 1 FACIA Y/SITE NAME CARE OF ADDRESS INFORMATION S�Q29 ADDRESS, NEAREST CROSS STREET ✓9wavgxa@ 0 PARTNERGIIP 0 SFATE AGENCY N H/l Max w5a0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL CD ❑ INDNIWAL ❑ COUNTY AGENCY Lj) CITU NAME ^ STATE ZIP CODE SITE PHONE p,WITH AREA CODE 47 TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 P ESSOR ✓Box if INDIAN EPA o NA ❑ I GAS STATION ❑3 FARM �ER TRUSRESETYLANOS or ❑ N of HIS SITE AT THIS SITE EMERGENCY CONTACT PERSON(PRI ARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N W=REA DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WNIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWENER INF & DDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ✓Box to millcale 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-ACENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS MUST BE COMPLETED) NAME — CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box m mdicele 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL AGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR TH LEGAL NOTIFICATION AND BILLING: E ❑ I. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,A TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRIMED&SIGNATURE) Un E LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N CILITY IDN Al of TANKS at SITE © 6 566 EEET70 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMITNU B R PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILEEDD� a 9•_�-- YES NO `— L O CHEC N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM IBI APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) • ` ( 1 /1501 IC\\ DATA PROCESSING COPY !1)