BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARCi, a FORM 'A': UNDERGROUND STORAGE TANK PROGRAM }R P JT SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I� ILI T nPN P COMPLETE THIS FORM FOR EACH FACILITY/SITE - MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT El GRANGE OF INFORMATION LJ ' PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NA CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSSGENO STPEET O CUIo'D iN1TO Q Lain EDEPA0 STATE ALAGEND ❑ INDIVIDUA CWNIVAGENLY CITY NAME STATE 711 CODE SITE PHONE X,WITH AREA CODE CA TYPE OF BUSINESS 2 DISTRIBUTOR 4 PROCESSOR ✓Box it INDIAN EPA ID X Y of TANK'N ❑ ❑ RESERVATION or ❑ AT THIS SITE ❑ I GAS STATION El FARM ❑ 5 OTHER TRUST LANDS 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 NIGHTSNAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) I4AME CARE OF ADDRESS INFORMATION MAILING oI S7flEE1'ADDRESS ✓Bux to md,cale 0 PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE 71P CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAM[ CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to.ndx:ale 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION D LOCAL-AGENCY 0 FEDERALAGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CIN NAME STATE 71P CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR SOTN LEGAL NOTIFICATION AND BILLING: 1. ❑ it. ❑ Ill. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME IPHINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS NI SITE 3 �� f�TTiT s 67 I I I 1p] CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE M E/1 - PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO �717 CHECKPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST! MORE TANK PERMIT FORM 'B'APPLICATION(S), UNI�THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2 HS)