BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM =o Z SITE �,FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I c COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERM TLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �� N 1 00 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DO W FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STRE ✓BRNidcale 0 PARTMRSIIP 0 STATE.AGUCY O 11 0 IWRPGRATNIN O Lc GEN ❑ iEDERAI AGENLY CITY NAME I 1 STATE ! ZIP CODE SITE PHONE N.WITH AREA CODE lir/ I CA TYPE OF BUSINESS: 3 DISTRIBUTOR <PROCESSOR ✓Bo.it INDIAN EPA ID p ❑ RESERVATION or ❑ P o1 HIS SITE J� ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS AT THIS SITE ll EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE It 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 inoicate 0 PARTNERSHIP Cl STATE-AGENCY Cl CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to inc,cate 0 PARTNERSHIP Cl STATE-AGENCY C CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 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. ❑ it. ❑ Ill.❑ 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 k =JURISDICTION If AGENCY X FACILITY ID M A of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID G APPROVED BY NAME PHONE N WITH AREA CODE PE PERMIT AP ROVAL DATE PERMIT EXPIRATION DATE / ENSUS TRACT G SUPERVISOR-DISTRICT CODE BUSINESSPLAN FILED NG ❑ :a] � vv 7, \ ERMIT AM UNT SURCHARGE AMOUNT FEE CODE RECEIPT M \ 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. 'IV) FORM A(3-2-88) DATA PROCESSING COPY