BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIV WATER RESOURCES CONTR BOARD p FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Vo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Q p 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 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION p ITE NAME �`1 1_ - DE Y, 1 Vj'1'�,�/..J NEAREST CROSS STREET ✓GObiMTc ❑ LOCAL GD ❑ STATEFOXIIA G90 AS I �I y-� �1`�/ ❑ C07DUAL" ❑ IOGJdGENY ❑ iE0BtA4AGENGY 1 a 119 ❑ INONIWAL ❑ Cq#IttdGENC! STATE ZIP/CODDE- SITE PHONE#,WITH AREA CODE t CA '�I USINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box N INDIAN EPA IDN N W TANIC RESERVATION or AT THIS SITE STATION ❑3 FARM ❑5 OTHER TRUST LANDS ❑ENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) ME(LAST,FIRST) PHONE N WITH AREA CODEPHONE N WITH AREA CODE NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PRONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY 13❑ CORPORATION ❑ COUNTY AGENCY ❑ FEDERAL-AGENCY STATE ZIP CODE PHONE p,WITH AREA CODE CITY NAME III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ClSTATE-AGENCY 11 ❑ NDRPORALION ❑ COUNTY AGENCY Q LOCAL-AGENCY ❑ FEDERAL-AGENCY STATE ZIP CODE PHONE N,WITH AREA ODE CITY NAME IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ASOVB ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. [:1 111.❑ 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&SIGNATURE) LOCAL AGENCY USE ONLY FACILITY ID N If of TANKS N SITE " CsgO�UNTY N JURISDICTION N AGENCY N q EEL CURRENT LOCAL AOENC ACI�10^ IC�_ APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER 1AI�PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ^ BUSINESS PIAN FRED DATE FILED �� LOCATION CCQDE CENSUS TRACT� 8UPERYISOR- ICT CODE YES NO a, IBY: CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1) MORE TANK PERMIT FORM i8'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88)