BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN10. WATER RESOURCESCONTROPdOARD �S� o".'♦ FORM `A': _ a UNDERGROUND STORAGE TANK PROGRAM ed SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m< �; COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 711 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ TLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE � I. FACILITY/SITE INFORMATION &A D ES — (MUST BE COMPLETED) N FACILITY/SITE NAME S7 A E OF ADDRESS INFORMATION D/cMn o7o M. ADDRESS NEAREST CROSS ST ET ✓Bo.m Firs& ❑ PARTNERSHIP ❑ STATE-AGENV 5 E .S� !,✓� o No nGx O COUNTY AGENCY ❑ ROERa(Acwa CITY NAME I STATEZIP CQDE SITE PHONE x,WITH AREA CODE S CA Y i,24 T/ TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PRqKSWR ✓Box if INDIAN EPA ID # - #of TANK'# F-11 GAS STATION F__] 3 FARM OTHER TRUSTION of ❑ ATTHISSITE NDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS' NAME( ST,FI,RRA kA iJ 4 PHONE W �REA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS' NAME(LAST,FIRS01) PHONE#WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE N WITH AR FA CODE S� II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ('A ✓Box to indicate 11 PARTNERSHIP 11 STATE-AGENCY l,Yf ❑ CORPORATION g l -AGENCY ❑ FEDERAL-AGENCY ElINDIVIDUAL leCOUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME /'I CARE OF ADDRESS INFORMATION t MAILING or STREET ADDRESS ✓BOX to indicate ❑ PART ERSHIP ❑ STAT&AGENCY ❑ CORPORATION -AGENCY ❑ FEDERAL-AGENCY 2 Z ❑ INDIVIDUAL OUNTY-AGENCY CITY NAME STAT ZIP CODE _ PHONE q,Vj(ITH AREA COD= 95'�f///I ,v/vJcl � IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. 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# AGENCY# FACILITY ID# If of TANKS at SITE o a z o I oc� d CURRENTLOCAL,OENC ACILI YID / APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBERYPERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUPERO TRICT CODE BUSINESS PLAN FILED DATE FILED ® YES [:] NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: Q / sassassa \ 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 ON p� 1 FORM A(3-2-88) \\ de DATA PROCESSING COPY ft