BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIP WATER RESOURCES CONTROIROARD FORM 'A': . UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m , ' COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I 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 C(C I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION �lTYof -S�G lc, J IW&INFCn 0 1 ?- ADDRESS NEAREST CROSS STREET ✓Bark rxcxe Cl PARTNEPWIP ❑ STATE AGENCY 1 ° o �" o �GEl E wt-AaEN�F- i4`AJN i o INIV°UAt n � CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA C DE CA TYPE OF BUSINESS: ❑ 2DISTRIBUTOR f7 OROCESSOR ✓Box if INDIAN EPA IDn Not TANK'S RESERVATION or El AT THIS SITE F-1I GAS STATION ❑3 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 �,,11LI -�, 71 NIGHTS: NAME(LAST,FIRST) l ' PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION �fJili�IJFl�E ISI;i,Plc-j -'-j_,-7_f of er,-Le __t MAILING or STREET ADDRESS I/Box to intlicate ❑ PARTNERSHIP O STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE . � ( Cl C�yL_ LJc_ Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME qq "p CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOR INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. - 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY* JURISDICTION N AGENCY N -- FACILITYID-9 -- - - - -- N of TANKS at SITE CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE a WITH AREA CODE �C(GI N �lU PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILED YES NO ❑ Z �CY CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: �\ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1 OR MORE TANK PERMIT FOR M 'B'APPLICATIONI UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-BBI