BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL ARD FORM A: UNDERGROUND STORAGE TANK PROGRAM =°°ter SITE Q FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I 1 COMPLETE THIS FORM FOR EACH CILITY/SITE "•� `" MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7,9ERMAIMINTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 __4 J I. FACILITY/SITE INFORMATION &ADDRESS —(MUST BE COMPLETED) w 00 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION �PrU LS N Zw G ADDRESS // Q' ,(p/ NEA ES CRO SSTRREET mature 0 PARTNERSHIP 0 STATE AGENCY CORPORATI/LINN v //' D�P� 0 INDMDUAL� ❑ CWNTYAGENIN 11 LOCAL AGENCY ❑ FEDERAL-AGENCY CITY NAME STATE ZIP CODE SITE RHO# q 1 W TH AREA CODE zl" CA TYPE OF BUSINESS: ❑ 2 DI UTOR ❑ 4 PROCESSOR -/Box if I DIAN EPA ID # S X o1TANK'n ❑ 1 GAS STATION FARM 5 OTHER RESERVATION of ❑ TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE U NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRE INFORMATION us MAILING or STREET AD MESS 2fl, to indicate 0 PARTNERSHIP 0 STATE-AGENCY /� CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 11V I L`AIAJ� % OINDIVIDUAL 000UNTY-AGENCY CITY NAME STAT E ZIP CODErM PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS—( UST BE COMPLETED) NAME �. � G CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS / ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 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. V 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION If AGENCY R FACILITY ID# If of TANKS at SITE CURRENT LOCP AAENCY FAC}ITY ID APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER H(J�(/-L(✓'�7 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIOlj,CODE CENSUS TRACT# SUPERVISOR-DISTRIC CODE BUSINES,P PLAN FILED NO ❑ DATE FILED CHECK* CC PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTAr BY /x� 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(8-2-88) 0 DATA PROCESSING COPY 0 /\