BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

9thO >ti STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ; * FORM 'A': u NLm UNDERGROUND STORAGE TANK PROGRAM 7 � ao SITEC] FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION V COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT IET5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION C Kr IUCD KA /s ADDRESS NEAREST CROSS STREET V11 GO Wolok, D PANIC] COWM70N El NmIP D STATE-AGENCY 513( /V HfexA%(tN D IwvouAL D Cawn-AGENCY ❑ Fmm+-AC�c CITY NAME STATE ZIP CgpE SITE PHONE N,WITH AREA CODE l-1IV0��) CA ��2;36 5 09) ,y 7-.3 36 TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Box it INDIAN EPA ID N N of TANK'N ❑ ❑ 5 OTHER RESERVATION or ❑ AT THIS SITE ❑ I GASS'TATION ©3 FARM ❑ LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYSNAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE < rr :s 06( -CncC (209) #7 -3136 S//'�- s/rt NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS `�! ✓Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL AGENCY D FEDERAL-AGENCY D INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME /n STATE ZIP CODE PHONE M,WITH AREA CODE /T S/A IS/i)- /tet Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 51A MAILING or STREET ADDRESS ✓Sox to od,w[. D PARTNERSHIP D STATE-AGENCY D CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY D INDIVIDUAL D 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 ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 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 COUNT/Y�# JURISDICTION M AGENCY R FACILITY IDN If of TANKS at SITE // CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE >�rYlP55l 5'u PERMIT NUMEp PERMIT APPROVAL DATE PER IT EXPIRATION DATE LOCATIN C71 CENSUS RA N� SUPERVISOR-DIS CODE BUSINESS PLAN FILED DATE FILED /p 3 YES F_ NO CHECKf PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM 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. FORM A(3-2-88) L 1