BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNr WATER RESOURCES CONTR BOARD FORM W: UNDERGROUND STORAGE TANK PROGRAM " "a SITE n FACILITY/SITE, INFORMATION and/or PERMIT A TION Z C'4(IFOPN�P COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F-] 1 NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANEND SIT I"� I ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) O CARE OF ADDRESS INFORMATION FACILITY/SITE NAME %,, ADDRESS NEAREST CROSS STREET ✓Bm to irtio# ❑ PARTNERSHIP ❑ STATE AGENCY 0 YO / A ' co TION ❑ LOCAL AGENCY ❑ FEDERA_AGENCY V IVIDUAL ❑ GODNtt A' C' CITY NAME To(rL`!O / STATE ZIP CODE SITE PHONE#iWITH A A CODE CA TYPE OF SINESS: ❑2 OISTRIBIITOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK'# 5 OTHER RESERVATION or AT THIS SITE 3 I GAS STATION ❑ 3 FARM ❑ TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) �H^�/Z�'�4 WITH AREA G � Onvs: NAME(LAST. PHoHEJ p CH AREA CODE DAYS NAME(LAST.FIRST) n'Y V S fSTV � PHONE p WITH AREA CODE NIGHTS'. AME(LAST, RST PHONE N WITH AREA CODE NIGHTS: NA (LAST.FIRST U I` 11. PROPER Y OWN R INFORMATION & ADDRESS — (MUST BE OMP TED) CARE OF ADDRESS INFORMATION FCI�NAME I -� ^ 0 PARTNERSHIP FI STATE AGENCY or STREET ADDRESS / ' K ✓BoxRPORATION ❑ LOCAL-AGENCY ❑ FEDERAL--AGENCY v INDIVIDUAL ❑ COUNTY-AGENCY t1K STATE ZIP CODE PH ,WITH ARBA CO '�� III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) 9S ^ J CARE OF ADDRESS INFORMATION NAME / 1 /`-� MAILING or STREET ADDRESS ✓Box to RATIIO Cl PARTNERSHIP D STATE-AGENCY �( ( � ` Cl CORPORATION Cl LOCAL-AGENCY ❑ FEDERALAGENCY F (�/ ❑ INDIVIDUAL ❑ COUNTY-AGENCY CIN NAME. E —/dl ZIP CODE PHONE#,WITH AREA CODE ISM 2,,4 ' IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS 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. DATE APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE 0 6 0 0 4 CURRENT LOCAL AGE Y FACILITY ID#� APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER (I� Fri PERMIT APPROVAL DATE PERMIT EXPIRATION DATE DATE FILED LOCATION yLCODE CENSUS�ACT#� SUPERVISOR-DISTRICT CODE BUSINESSPELSN FILED NO V II RECEIPT# BY: CHECK# PERMIT AMOUNT SURCHARG AMOUNT FEE CODE THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORM¢fL Y N QH �/� FORM A(3-2-88) a 9� S DATA PROCESSING COPY