BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNM WATER RESOURCES CONTR�BOARD �* f 5M FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m , COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 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 6 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME �"� CARE OF ADDRESS INFORMATION rrec! A.l'X ZNEAREST ADDRESS CROSS STREET ✓BoobPlink ❑ PARTNERSHIP ❑ STATEAGENLY N ❑�� yyO0APoNATION ❑ LOCALAGENCY ❑ FR[MLAGENCY CQi'INDIVIDUAL ❑ COUNTYAGENNCITY NAME • ZIP CODE SITE PHONE N.WITH AREA CODE rA,�flN -A 6� TYPE OF BUSINESS. ❑ DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID a ❑ 1 GAS STATION FARM ❑ 5 OTHER RESERVATION or ❑ ,N o1 HIS SITE TRUST LANDS AT THIS STE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYSNAME(LAST,FIRST) PHONE k WITH AREA CODE . x-derd - R -. NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 0 2o9 - 6'1- 6 II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NA % /• CARE OF ADDRESS INFORMATION (jXe 0 1 MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL 11COUNTY-AGENCYCITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION e MAILING or STREET ADDRESS ✓Box toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY S JURISDICTION N AGENCY N FACILITY ID R R of TANKS at SITE " ® O S" g D C/ 0 /J CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE 'r)cwt)c-(6 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED _27, Z'L. YES � NO 7 \ rz CHECK k PERMIT AMOUNT SURCHARGE A UNT FEE CODE RECEIPT N BY: NV V THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'S'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. V FORMA(3-2-88)