BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNba WATER RESOURCES CONTROL BOARD FORM W: UNDERGROUND STORAGE TANK PROGRAM Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ T PERMAN NTLY CLOSED SITE IJ ONE ITEM D54INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W OD FACILITY/SITE NAME 'N CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bw wi ❑ ❑ STATE AGElKI u5}ri N �c✓ o IRoino AnGR MALLOCAL= ❑ FEDERAL-AGS CITY NAME ) STATE ZIP cgpE / SITf,PHOLJ�N.WITH qREA fv ST0cl_--rd,e 99 `%V/09 6 TYPE OF BUSINESS: ❑2 DISTRIBUTOR 4 PRIXESSOR ✓Box if INDIAN EPA ID # It of TANK'RESER �J ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUSTYLANDS or ❑ ATTHIS SITE 2 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE OM 1 saw 20 Cl Y62— 0�/y NIGHTS! NAME(LAST.FIRSTI PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAMEC of 57�� CA`RE OPADDRESSINFORMATION MAILING or STREET ADDRESS V "n(✓N Box toindicateARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE &/-)- 1'S 202 I ?f, III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME (�VWV�4G. 0� / CARE OF ADDRESS INFORMATION \� J.- MAILING or STREET ADDRESS ✓Bax to Indicate ARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION LV LOCALAGENCY ❑ 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. ❑ 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 COUNTY# JURISDICTION If AGENCY# FACILITY ID N #of TANKS at SITE = = = 16101 JTE4iO 1010101 -4 CURRENTLOCAL AGENCY FACLILITY IDN�� I APPROVED BY PHONE N WITH AREA CODE PERMIT NUMBER I^TN PERMIT APPROVAL DATE PERMIT EXPIRATION DATE /2 UpfS�( LOCATION CODECENSUS T11ACT Y SUPERVISOR-DI TRICT CODE BUSINESS PLAN FILED DATE FILED d 23 5-0L! 2D res ❑ No CHECK# 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. /FORM A(3-2418) W �_v DATA PROCESSING COPY /// J