BILLING - Laserfiche WebLink

Home Browse Search

SATE OF CALIFORNIA WATER RESOURCES CONTROBOARD e Flo MUNDERGROUND STORAGE TANK PROGRAM bo S TE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONo p COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PEpMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 49.0 w I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) p FACILITY/SITE IN pD p CARE OF ADDRESS INFORMATION 1% bit kc ADDRESS NEAREST CROSS STREET ❑✓Cow0 IQN O PAWNEA ENCY O KDEPAISENICY -AGENCY - /a� ��1 f l(A 5 ❑ INDIVIGIIAL CWNttAGENC! CITY NAME 'V STA ZIP ZIP CODE �� SITE PH ONE N�WITN�A11L l TYPE OF BUSINESS: ❑ p DISTRIBUTOfl ❑ ESSOR Box if INDIAN EPA IDN S �GJv/J(/AN o1 TANK'sOLJ 3�., 6 RESERVATION or ❑ AT THIS SITE ❑ 1 GAS STATION ❑3 FARM 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST FIRST) N WITH AREA CODE DAY NAME(LAST,FIRST) PHONE#WITH AREA CODE , . PHONE PHONE N WITH AREA CODE NIGV/•HI`T'SV/:/hNAME(LAST IRST) O O PHONE N WITH AREA CODE NIGH S' NAM (LASTF , I RST) < I'�1 ✓_"'✓' [ ( l ! 7 ' II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION SA MAILING or STREET ADDRESS n ✓Box to indicate [3PA TNERSHIP ❑ STATE-AGENCY q ❑ CORPORATION CAL-AGENCY ❑ FEDERAL-AGENCY aD, t ✓bZ. ' I /1 V ❑ INDIVIDUAL COUNTY-AGENCY CITY NAME STATE - ZIP ODE / PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADORE S — (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP El STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE#,WITH AREA CODE CITY NAME 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.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY COUNTY M JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE CURRENT LOCAL AGENCY EAC'LITY 10# , APPROVEDOBY NAME PHONE N WITH AREA CODE PERMIT NUMBER JCPr v(/ PER IT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-D TRICT CODE BUSINESS PLAN FILED DATE FILED 3�3- 0 7 Q/!/1 ;2-a YES [] NO l 3BY: CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N //// 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. L -I FORM A(3-2-8B) 0 / \VI)V' DATA PROCESSING COPY