BILLING 1985-2003 - Laserfiche WebLink

Home Browse Search

jTATE OF CALIFORN* WATER RESOURCES CONTROL BOARD ys'"'` FORMA': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m , o 1� COMPLETE THIS FORM FOR EACH FACILITY/SITE �""J°"�" MARK ONLY ®I NEWPERMIT ❑3 RENEWALPERMIT E]5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM 2INTERIM PERMIT 4 AMENDEDPERMIT 6 TEMPORARY SITE CLOSURE ®/ I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W FACILITY/SITE NAME CARE OF ADDRESS INFORMATION I u ADDRESS NEAREST CROSS STREET ✓BK6�inSrye ❑ P,WINERWIP ❑ STATE AGENCY s B❑ ROM ON ❑0 LOCAL ICY ❑ EOEPAL AGENCY CITY NAME STATE ZIPCODE j4ZEPH Ep,WITHAREA CODE CA 9 los 9yk TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box N INDIAN EPA ID k RESERVATION or R of TANK'4 ❑ T GAS STATION ❑3 FARM OTHER TRUST LANDS ❑ ATTHIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME(LAST,FIRST) PHONE K WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE aj -1 04, NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 9 ,3q&_9Sz:7_ IL PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL O COUNTY-AGENCY CITY NAME STATE ZIPCODE PHONE At,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. ❑ It. ❑ 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 M AGENCY N FACILITY ID X N of TANKS at SITE ® 1010 1 101 (011161 CURRENT LOCAL AEN FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE 77 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA cm CODE CENSUS TRACT N SUPERVISOR-DI TRICT CODE BUSINESS PLAN FILED DATE FILED / p[J Z YES [:] NO [:] CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: 1 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 ON ,W\1 FORM A(32-SR, *aw DATA PROCESSING COPY