BILLING_1986-2001 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA IG WATER RESOURCES CONTROL EcInD UJL FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �- ��U iox NSP COMPLETE THIS FORM FOR EACH FACILITY/SITE — MARK ONLY ❑PERMIT � 3 RENEWAL PERMIT CHAN�INFORMATION �Ej 7 PERMANENTLY CLOSED SITE ONE ITEM O INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPSURE Ov� - 0 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) _ C OF ADDRESS INFORMATION FACILITY/SITE NAME STATE ENCY REST ROSS STREET ✓CORP PmRAT ❑ PABAL AGEN ❑ FEDERAL EDERA AGENCY N ADDRESS ❑ GIDUA➢pN �l' ini,e ❑ FEpEPAbAGENCY CJT //0// ❑ INpIVIpUA NE HL WITH A co / STATE �I CODE �IT PHONE p.WITH AREA CODE (� CITY NAME CA 533 aU _30/ PE OF BUSINESS: 7 2 DISTRIBUTOR 4 PROCESSOR ✓Box it INDIAN ID N #of TANK's THER RESERVATION or ❑ (3 AT THIS SITE a 1 GASSTATION � 3 FARM TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) PHONE N WITH AREA CODE �YS'. NAME(LAST,FIRST) - PHONE N WITH AREA CODE _Y/S�'.�LNAM,/E�(LAnST,FIRST) 0 t'1� MI'llV _1�1/ 3 —310/ PHONE U WITH AREA CODE HTS'. NAME(IAST,FIRST) PHONE#WITH AREA CODE GHTS'. NAME(LAST,FIRST) /N ahly D It. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) E CI IF ADDRESS INFORMATION s/ v ✓Box toi HAIIe ❑I��I�P�A`'R�T^NERSHIP ❑ STATEFEDERAL-AGENCY L-AGEN GENCY AILING or STREET ADDRESS �' ❑ CORPORATION IF L-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL COUNTY-ADEN NAME - TATE CODE rRH NE q,WITH AREA CODE 533G� oti �3-3/0/ III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) LA F ADDRESS INFORMATION j ,tTl el / ✓Box to Indicate LJPARTNERSHIP LlSTATE-AGENCY INC or STREET ADDRESS ❑ CORPORATION LZ,Eec'XL-AGENCY ❑ FEDERAL-AGENCY V (/ ❑ INDIVIDUAL ❑ COUNTYAGENCY TE CODE yUONE p.WITH AREA CODE NAME 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY F COUNTYJURISDICTION AGENCY# S FACILITY ID# #o1 TANKS at SITE 0 CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE N WITH AREA CODE i 0 11 PERMIT NUMBER RMIT APPROVAL DATE PERMIT EXPIRATION DATE Z ATION CODE NSUS TRACT N�D PERVISOR-DISTRICT CODE BUSINESS EAN FILED NO ❑ TE FILED S L/yfBY: CHECK# ERMIT AMOUNT URCHARGE AMOUNT FEE CODE RECEIPTM 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) ' S �,� DATA PROCESSING COPY