BILLING 1985-1990 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNI? WATER RESOURCESCONTRO91OARD FORMA': UNDERGROUND STORAGE TANK PROGRAM = " z SITE /7 I FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I COMPLETE THIS FORM FOR EACH FACILITY/SITE MARKONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 015 CHANGE OF INFORMATION ❑ 7 PERMAY�D SITE ?� ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Iq 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) CD FACILI SITENAME pi` CARE OF ADp E$S INFORMATION ADDRESS NEARESTCRO STREET ✓Pn%N Mluk ❑ PARTNEMP ❑ STATE-AGENCY (/n..,,y/� ❑ y0FFOIA ON ❑ LOCAL.Aom ❑ FEDEAALAGENCY Ate+ �vL V hA O 19'INDIVIWAL ❑ COUNTY AGENCY CITU NA STATE ZIP CODE SITE PtiONE p,WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Boz N INDIAN EPA 10p - Itof TANK'e RESER ❑ 1 GAS STATION El FARM �5 OTHER TRUSTVATION LANDS or ❑ AT THIS SITE D I EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS NALAST,FIRST) PHOPLE IWITH AREA CODE DAYS ME(LAST,FIRST) PHONE WITHAREACODE NIGH T$:/NAME(LAST,FIRST) PHONE qLVTH AREA CODE NIGHTS: AME(LAST,FIRST) PHO WITH AREA CODE II. PROJ\PI/EARTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME S /-A CARE OF ADDRESS INFORMATION MAILING STREET RESS ✓Box to indicate ❑ PARTNERSHIP 11 STATE-AGENCY ❑ CORPORATION 11 LOCAL-AGENCY ❑ FEDERAL-AGENCY �.. _O T ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE( ZIP ODES X51 PHONE N,WITH AREA CODE C/4 �(.'i III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME n CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate El PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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. It.❑ 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 N JURISDICTION B AGENCY B FACILITY ID B N of TANKS BI SITE oat CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE F MBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CODE CENSUS TRACT M SUPERVIS R-DISTRICT CODE BUSINESS PLAN FILED / DATE FILEDD YES NC"'IL�J(PER AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88) DATA PROCESSING COPY 0