BILLING - Laserfiche WebLink

Home Browse Search

... „^wNmngp'dw'„1�i's^K"'I�r P�Y!`M1'JRl;:e,,;.,�.lm ,::e,,ml. ,.�,..,..,{�(m•RR .�,..�,�,4,.. .oy. _..:T.aa��g7'P. . STATE OF CALIFORN WATER RESOURCES CONTABOARD W. s FORM 'A': UNDERGROUND STORAGE TANK PROGRAM " ""'m SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION b COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE v y I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) ° F ILITY/SITE NAMEG n/, O� E OF AOORESS INFORMATION �I_320 KESS EAREST CROSS STREET BoxGloyi tlirale ❑ PARTNERSHIP ❑ STATE AGENCY N PIP �/}, 711 GDRFDAATIDN g4CALAGENCY ❑ FEDERAL AGENCY CA INDIVIDUAL ❑ COUNTYAGENCY .4 NAME STATECODE PHONE a,WITH AREA CODE 6 is CA 7 9 8 -3s VqE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a , of RESERVATION or If 1 GAS STATION E] 3 FARM OTHER TRUST LANDS ❑ -3 �(J Alt-- AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) MERGENCY CONTACT PERSON(SECONDARY) D B: NAME(LAST,FIRST PHONE N WITH AREUrA CODE DAYS'. NAME(To.FIRST) PHONE a RE WITH AA CODE HTS: NAME(LAST,FIRST)) PHONE pVOLEKAREA,CODE GHTS: NAME(LAST,FIRST) PH E a WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) MEF ADDRESS INFORMATION / s �r sem' ING or STREET ADDRESS ✓Box to lndlcare ❑^ PA3TNERSHIP 13 STATE-AGENCY CORPORATION I!4*AL-AGENCY ❑ FEDERAL-AGENCY INDIVIDUAL ❑ COUNTY-AGENCY TY NAME STATE ZJQCODE NE a.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME EOFADDRESS INFORMATION �r � L s/ V Slr�/� STG AILING or STREET ADDRESS ✓Box to Indicate El P){6iNERSHIP LlSTATE-AGENCY CORPORATION OCAL-AGENCY El ❑ INDIVIDUAL ❑ COUNTYAGENCY NAME SIATE ODE NE a,WITH AREA CODE 9 L IV. GAL NOTIFICATION AND BILLING ADDRESS NECK ONE(1)BOX 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 APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY rGim UNTY# JURISDICTION# AGENCY# FACILITY ID# of TANKS at SITE o 0o )- CJJRFUENT LOCALAGEFACILITY ID If APPROVED BY N E PHONE#WITH AREA CODE 'PEAMIT NUMBER JC C,/Q T APPROVAL DATE PEE YlT EXPI TO DATE L ION CODE CENSUS TRACT# R SOR-DISTRICT CODE SINESS PLAN FILED DA FILED J67a YES NO /17 ECK# PERMIT AMOUNT RCNARGE AMOU T FEE CODE RECEIPT k BY: 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. FORMA(3-2-88) 0 DATA PROCESSING COPY 0