BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNI jo WATER RESOURCES CONTR*ARD u �ht iuuti rhe. FORM 'A': UNDERGROUND STORAGE TANK PROGRAM z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION „ I COMPLETE THIS FORM FOR EACH FACILITY/SITE c"'eovgn FMARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE F"a ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSUREcc 3 I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) a FACILITY/SIT NA^ ` CARE OF ADDRESS INFORMATIC i I o Y, T� re . ZL ADDRESS NEAREST CROSS STREET ��✓S�o mOtlA 0 PARTNERSHIP 0 STATE AGENCY 5? I ..B'C`0.9POPAigN 0 LOCALAGENCY 0 RDEINL-AGENCY 35 f Y C INDi C COUNT AGENCY CITY NAME STATE ZI$C�E �� SITE PHONE N,WITH AREA CODE S�k TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR I/Box it INDIAN EPA ID It (w��II`J r l STATION ❑3 FARM ❑ 5 OTHER TRUSTY ATION LANDS or ❑ �— AT TRIS SITE GAS Sv u 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 NIGHTS' NAME(LAST,FIRST) 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 MAILING or STREET ADDRESS ✓Baa to Indicate 0 PARTNERSHIP C STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY C FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box loindicale 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY C FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION N AGENCY M FACILITY ID N M of TANKS at SITE 3E 100 1 ( Ii= 10voo CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE N WITH AREA CODE l L 5-0 15 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE JCLHECK# CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN(ILEO DATE FILED dx3OU L A` YES ❑ NO ❑ L- t .at-y PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY:) j 39IIoTHIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. RM A(3-2-88) • DATA PROCESSING COPY .