BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIP WATER RESOURCES CONTRAOARD ;s` , .•'a,=F FORM A : UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EA7 FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAMECARE OF ADDRESS INFORMATION c k e6e + ADDRESS NEAREST CROSS STREET ✓GO m WIC88 ❑ PARTNERSHIP 0 STATE AGENCY st• E Mq 6eL 0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL AGENCY [• ❑ INDNIOUAL 0 COUNTYAGENCY CITU NAME STATE ZIP CODE SITE PHONE a,WITH AREA CODE F.'fd N CA TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bax if INDIAN EPA ID a ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHEfl TFtUSTYANDS or If of TANK's ❑ qT THIS SITE EMERGENCY CONTACT PERSON(P MARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE IGHT NAME(IA FIRST) PHONE a WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAMEp „/ CARE OF ADDRESS INFORMATION MAILI G or STREET AD/D�RESS /- ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY C y AA'�w N \� 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCYVM. O 0 INDIVIDUAL Cl COUNTY-AGENCY CI NA E STATE ZIP CODE PHONE N.WITH AREA CODE VC' elf zos`' III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bax to inocate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY 0 INDIVIDUAL 0 COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADORE”SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. 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 CO�UNTYY# JURISDICTION N AGENCY N FACILITY IDM N of TANKS BI SITE L-1� ] = = Z 4� C t'J Crj CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PNONE M WITH AREA CODE rpvfm Z-1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE 3 Q -3Z3 YES NO [:] C CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN Y; 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM '8'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION Y. FORM A(3-2-e8)