BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD �! J hA'� M1f Y_ A FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE A FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION (/ COMPLETE THIS FORM FOR EAC AGILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7,R&RWNENTLY CLOSED SITE ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET D PAATNERSlP D STATERAG.FNY 5 uO IryG EN D FEDE4Af# N Dac.�r Cl INDIVIDUAL CITY NAME l� / STATE ZIP OOE SITE PHONE N,WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Rax A INDIAN EPA 0 N ❑ ❑ ❑ TRUST LANDS a ATIf TANSY a I GAS STA710N 3 FARM 5 OTHER ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(�AS�T,FIRST) PHON N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE l�vS9X 1 1.114of f")r y — 361 Saw p NIGHTS: NAME(LAST,FIRST I I PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME , f ✓;�� y-r- CARE OF ADDRESS INFORMATION MAILING or STREET ADORE !$$_ ti / I�II/Fy�)•/v, ox to indicate D PARTNERSHIP D STATE-AGENCY �(�/.SU[ CORPORATID ON LOCAL-AGENCY D FEDERAL-AGENCY A INDIVIDUAL D COUNTY-AGENCY CITY NAME / STATE ZIP C04E �, PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME ,n y CARE OF ADDRESS INFORMATION 7 jq MAILING or STREET ADDRESS D' ox to in0icale ❑ PARTNERSHIP D STATE-AGENCY 1 CORPORATION ❑ LOCAL-AGENCY D FEDERAL AGENCY r O 30010 D INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE _ ZIP CODES PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDIIEBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION M AGENCY S FACILITY ID R K o/TANKS at SITE Eml av ) JEIRO I 0161 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE F WITH AREA CODE 0vGVH PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 2/z-2-/91 LOCATION CODE CENSUS TRAC4T N SUPERVISOR-DISTRICT CODE BUSINESS RAN FILED DATE FILED T_Z� y u YES NO CHECK t PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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. FORMA(3-2-8B)