BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM u . SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F ILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER ENTLY CLOSED SITE 1"a ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 —4 I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) DO OC! FACILITY/SITE NAME CARE OF ADDRESS INFORMATION )S ADDRESS �yL' � ' w NEAREST CROSS STREET ✓Bm to intlira[e ❑ PARTNERSHIP ❑ STAiE AGENCY 3 Rw 1L ❑ COAPOPATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY ��' 111 VVw Cl INDNIDUAL ❑ COUNN AGENCY CITY NAMESTATE ZIP CODE SITE PHONE#WITH AREA CODE r a CA SZ d TYPE OF BUSINESS'. 2 DI BUTOR ❑ 4 PROCESSOR I ✓BOX if INDIAN EPA ID # RESERVATIONor X of TANK's ❑ 1 GAS STATION FARM E] 5OTHER 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#WITH AREA CODE aAm e U tC V NIGHTS: NAME(LAST.FIST) PHONE WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S ov14.a MAILING or STREET ADDRESS ✓Box to intficate ❑ PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME 56L41%A4e & ' — 1y CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to,,ft.te ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY K JURISDICTION If AGENCY It FACILITY ID F K of TANKS at SITE m Z41 lz> 141 1 d dU 1 / CURRENT LOCAL AGENCY FACILITY ID It APPROVED BY NAME PHONE k WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT VOIDE BUSINESS PLAN FILED DATE FILED VES NO ❑ /0 CHECK PERMIT AMOUNT SURCHARGE A OUNT FEE CODE RECEIPT Of BY:�� """"�� 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. FORMA(3-2-88) DATA PROCESSING COPY