BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNO WATER RESOURCES CONTR%... BOARD 4; FORM `A': UNDERGROUND STORAGE TANK PROGRAM ,gym SITE �^ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� COMPLETE THIS FORM FOR EACH:f LITY/SITE 4"', "p, MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERM CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 1'k7/i✓/' ML}i2`` ADDRESS / , �/� NEAREST CROSS STREET ✓Bwc to indicate ❑ PARTNERSNIP ❑ STATE-AGENCY ^ / A A ❑ COLORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY 1 �V Cl INDIVIDUAL ❑ CWNTY-AGENCY CITY NAME STATE CZIP CODE i SITE PHONE AREA CODE /✓!76 A TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOTRESERVATION Box it INDIAN EPA ID p or IY of TANK'tt ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHERUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE f3 �uf Zoe=z _717, z3 70 [NIGHTS: NAME(LAST,FIR ) PHONE N WITH AREA CODE NIGHTS: NA (LAST,FIRST) PHONE A WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) / p A/ CARE OF ADDRESS INFORMATION NAME Az l'v C� D G-7 C MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION 1-1LOCAL-AGENCY ElFEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE q,WITH AREA CODE �� /�J— DE PHONE Z3 III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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 ADDREU SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ 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 N JURISDICTION M AGENCY N FACILITY ID 8 M of TANKS at SITE 3 � 11/13 CURRENT LOCAL AGENCY FACILITY ID 0 APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED p /� .2,6j YES ❑ NO ❑ �,'/UJ CHECK i PERMIT AMOUNT SURCHARGE AMOUNT --jFEE CODE RECEIPT K 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 FORMA(3- -88) \\I�