BILLING 1988-1989 - Laserfiche WebLink

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Sex auaae� '�f STATE OF CALIFORNIAWATER RESOURCES CONTRO OARD FORM AA': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION �' I IM-I✓C' `J ADDRESS/ NEAREST CROSS STREET ✓ nOeAle ❑ PARTNERSHIP D STATE AGENCY Woo L_L O Q e: RATIDN D LOCAL-AGDO D AGENCY ❑ INDNIDUAI ❑ CDUNTYAGENCY CITY NAME STATE ZIP ODE SITE PHONE I.WITH AREA CODE CA 3 TYPE OF BUSINESS' 2 D TRMUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID x / Vv • Mol TANK'Y flESERVATION or ❑ AT THIS SITE ❑ 1 GASSTATION FARM ❑ 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE x WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE If WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ to indicate D PARTNERSHIP D STATE-AGENCY CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY ❑ INDIVIDUAL D COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE x,WITH AREA CODE I 6 III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indcate D PARTNERSHIP C STATEAGENCY ❑ CORPORATION C LOCAL-AGENCY D FEDERAL-AGENCY ❑ INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE x.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: 1. ❑ if. 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* JURISDICTION R AGENCY M FACILITY ID R R of TANKS at SITE F � c CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE UNi! PERMIT NU BER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILEDEE 17 1 C7'j� a oC YES NOCHECK Y PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 ONLY. FORM A(3-2-88)