BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SLI Aw" SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION J" COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT �'ICHANGE OF INFORMATION //��'�� E] 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ p INTERIM PERMIT El AMENDED PERMIT ❑6 TEMPORAM SITE CLOSURE(y U I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) I c CILITV/SITE NAME C EOF AD(1RESS INFORMATION ADDRESS / ,blEAREST CRRO/SSS S,[T/q/EET — Bael rale 0 PARTNERSHIP 0 STATE AGENOf ✓/✓[� ❑ INpNIDUAI GN ❑ COUNTY PGENCI ❑ FIn AGEN(,, NAME STATE zie CODE SOFE PHONE N,WITH AREA CODE ry b CA S3 ZO d Za-TY6r3fi 3s3 PE OF BUSINESS: 2 DISTRIBUTOR [:] d PROCESSOR ✓Sox it INDIAN E N RFSEATIOI❑ 1 GASSTATION ❑ 3 FARM OTHER TRUST LANDS o ❑ (0 AT THIS SITE / EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE k WITH AREA CODE DM Al- a jm, C A5 /e GHTS. NAME(I-AST.FIRSV PHO E N ITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) &� �3 E OF ADDRESStI N,F�O�RMATION vD ING or STREET ADDRESS ✓Rox t.odicate 0 PARTNERSHIP 0 STATEAGENCY p 1-9❑ CORPORATION 0 LOCALAGENCY1:1FEDERAL-AGENOY er �� 0 INDIVIDUAL 0 COUNTYAGENCY NAME S TE CODE E N,WITH AREA CODE / 9S-3ui 83� III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) E CARE OF ADDRESS INFORMATION LING or STREET ADDRESS J Rox to indicate 0 PARTNERSHIP 0 STATE-AGENCY C/ ❑ CORPORATION 0 LOCAL AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY NAME E ODE P NE#,WITH AREA CODE ; Z IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS 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# JURISDICTION# AGENCY# FACILITY ID# 0 of TANKS at SITE RR T LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER P T APPROVAL DAT PERMIT EXPIRATION DATE Ei SUSTRACT 0 S ERV OR-DISTTR/ICT CODE BUSINESS PLAN FILED FILED p� YES NO ❑PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N Y: I IF 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. FORM A(3-2-88) \/ DATA PROCESSING COPY