BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIP WATER RESOURCES CONTROL /..- FORM `A': ' UNDERGROUND STORAGE TANK PROGRAM =" o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONS . o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7f 9-PERMANENTLY CLOSED SITE ONE ITEM ❑ Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 00 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) -4 CD FACILITY/SITE NAME CARE OF ADDRESS INFORMATION �0. 640r ADDRESS NEAREST CROSS STREET ✓Sox laMae ❑ PARTNERSNIP E7 STATEAGENCY 2 C /� O ❑ COFPORATION ❑ LOCAL�AGENCY CIFEDERALAGENCY L� L/ V ❑ INDIVIDUAL ❑ COUNTFAGENCY CITY NAME STATE 21P CODE SITE PHONE q,WITH AREA CODE Y---N CA 0I. ao° y(o U TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box d INDIAN EPA ID a so TANK's ©'�GASSTATION [:]3 FARM ❑5 OTHER TRUSTYLANDS or ❑ AT HIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAM (LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE Fera C24,e. -. L,2)- Rog 4LvS -I-)to NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I ✓Be.to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY 1 v1 E3 CORPORATION 11 LOCAL-AGENCY 11FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STAT ZIP CODE PHONE a,WITH AREA CODE SaOT III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION _ cc —a MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY Cl CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE a.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. 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 8 SIGNATURE DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION# AGENCY R FACILITY ID Al #of TANKS at SITE ® U lo / 10 10 10 1 U CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE N WITH AREA CODE CA- PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRI T CODE BUSINESS PLAN 1. YES FILED DATE FILED ❑ NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM 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 FORMA(3-2-88) ' DATA PROCESSING COPY 0 \,