BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNI)s- WATER RESOURCES ONTROr90ARD FORM LA': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; o COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ TLY CLOSED SITE F+ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION ADDRESS , NEAREST CROSS STREET ✓Bm bmdnle 11PARINERSHIP ❑ STATE-AGENCY CI CORPORATION 11 LOCAL AGENp El FEDERAL AGENCY So41p-000--76u, ❑ INomoUAL ❑ COUNW AGENa CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE �7ock7o a CA 2a �� Z TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA IDN #of TANK1 ❑ 1 GASSTATION ❑3 FARM ❑ 5 OTHER TRUST RESERYLANDS ATION or ❑ AT THIS SITE 3 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. N E ST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(y`ST,FIRST) PHONE N WITH AREA CODE NV /�G ZQ _ �12��77 JA�w2, NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE 5Allylk 11. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME A-R-T Ko P.ocK CARE OF ADDRESS INFORMATION MAILING or STREET AD S ��111 ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY g D O /A O/LSI ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY /C•e / ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAMEv�� STATE 21P CA Il sv PHONE N AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) 7 NAME CARE OF ADDRESS INFORMATION 4L MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.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. ❑ 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 M JURISDICTION N AGENCY# FACILITY ID# Of of TANKS at SITE M I A 0 1 l 5 10101 v CURRENT LOCAL AGENC FACILITY ID# APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIOON CODE CENSU�Tf1ACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED / OG ],p res ❑ No CHECK# PERMIT AMOUNT SURCHARGE AMOUNT 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 ONLY, S FORM A(3-2-88) Yw� DATA PROCESSING COPY