BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFOAIA WATER RESOURCES CONTROL BOARD 1" FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ; " o SITE fes'-] FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I� ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE :D I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) a) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION e/ M # 33 ADDRESS NEAREST CROSS STREET ✓ rdl.k ❑ PARTNERSHIP ❑ STATE AGENCY / CORPORATION ❑ LOCALAGENCY ❑ FEDERAL AGENCY /Y1 o foe . /Cra es ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA 4sa TYPE OF BUSINESS: ❑2 DISTRIBUTOR L '14 P SSOR ✓Box II INDIAN EPA ID x ❑ If of TANK's 1 GAS STATION ❑ 3 FARM 5 OTHER TRUSRESETLANDS or ❑ W E^--- AT THIS SITE IF— EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE 6 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INF RMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ ox lo,ftcale 13PARTNERSHIP ❑ STATE-AGENCY ,,�xx CORPORATION 13LOCAL-AGENCY11 FEDERAL-AGENCY O r D /✓ ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE C;;�4coC'h' 1757.20 III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING ar STREET ADDRESS ✓ x to intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,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. IV 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# AGENCY# FACILITY ID If #of TANKS at SITE 3q --)-= 1odn CURRENT LOCA AGENCY FACILITY ID a APPROVED BY NAME PHONE#WITH AREA CODE K4 ,M07j PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3p73 YES NO to X — c/ CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECENT BY: 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) . • DATA PROCESSING COPY