BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNAoct.. WATER RESOURCES CONTRa[`/ARD ° W_ FORM 'A': UNDERGROUND STORAGE TANK PROGRAM _ �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION G COMPLETE THIS FORM FO EACH FACILITY/SITE it MARK ONLY Wu 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 z 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) F CILITY/SITE NAME E OF ADDRESS INFORMATI N S 5 ADDRESS q.,� NEAREST CROSS STREET ✓3nYN nCiok ❑ PARI MIP ❑�SiATE-AGENCY N LY�SVN./ S ❑ OJI✓RMTON ❑ LOWLAGENCY ; FEDBML.AGBILY -_y_ Cl INDIVIDUAL ❑ CWNM-AGENCY CITY NA E STATE ZIP CODE SITE P NEN,WITH AREA CODE CA (o TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4PROCESSOR ✓Box it INDIAN EPA ID a Eof TANK' ❑ I GAS STATION Ll3 FARM 5 OTHER TRUSTVATION LANDS Dr ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) 0 YS: NAME(LAST,FIRST) ONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE (LISIRST) L - NIGHTS: NAME(LAST.FPHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS —(MUST BE COMPLETED) Np CARE OF ADDRESS INFORMATION Vl MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ TATE-AGENCY S ❑ CORPORATION ❑ LOCAL-AGENCY EOERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITV.yMAE ST . ZIP CODE PHONE p,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE/COMPLETED) 32 NAI \ CARE OF ADDRESS INFORMATION MAILING m STREET ADp I It��✓lM'r/f^RVX1_ ,x ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY Gam/ U/'•,F tO'C' ❑ CORPORATION ❑ LOCAL-AGENCY FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY QTv STATE ZIPS PONE p, ITH AREA CODE/ IV. LEGAL NOTIFICATION AND BILLING ADDRESS 3 DQ Z CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ 11- 1:1 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 It AGENCY# FACILITY ID# If of TANKS at SITE 0 1 rD1 16 101012, 1101 CURRY OCAL AGENCY FACILITY ID# P BY NASIEI 1 PHONE M WITH AREA CODE 1 Z Il PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATI NDATE LOCATION CODE CENSUS TRACTT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED ❑ DAFILED 2 2J 3 88 2 ❑ YES NO 8 r Ito CHECK# PERMIT AMOUNT SURCHARGEAMOUNT FEE CODE RECEIPT# 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 ON FORM A(3-2-88) DATA PROCESSING COPY , j