BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNM WATER RESOURCESCONTRdCBOARD e` � 'e FORM 'A': UNDERGROUND STORAGE TANK PROGRAM (%T SITE � FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� l o COMPLETE THIS FORM FOR EACH FACILITY/SITE `^�neae�° MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE IMA, ONE ITEM Q2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE r10 00 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) D7 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION nD a I I v-e r %'c3,, �— ADDRESS ,�/\' NEAREST CROSS STREET ✓Bm IO iTNCBIe ❑ PpATNBRHIP ❑ $TpTF.pGEry4y S t I 1 );j r I ❑ COwoMTllN ❑ LODL_IAGENCY 11RIEW-AM0 $RDVIOIIAL ❑ WONVAGENCY CITY ME STATE ZIP CODE SITE PHONE N.WITH AREA CODE sc c lc� , Q X32 U CA Uri TYPE OF BUSINESS: 2 DISTRIBUTOR F—I 4 PROCESSOR ✓Box i/INDIAN EPA ID p RESE❑ 1 GAS STATION ❑3 FARM �^J-DTHER TRUSTLANDS ATION or ❑ - Nof HIS Sl AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME ILAST,FIRST) �. PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST]k_�— PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE b,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME ..,, nn CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ III.El THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION# AGENCY# FACILITY ID R R of TANKS at SITE 3E = = ID101iLNI 'll © Db 2 CURRENT LOCAL AGENCY FACILITY ID X APPROVED BY NAME PHONE N WITH AREA CODE U 2s PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DIST ICT CODE BUSINESS PLAN FILED DATE FILED UL YES NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTk BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY FORM A(3-2-88) DATA PROCESSING COPY