BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIM WATER RESOURCES CONTROL�BOARDy��"""�'r"� FORM `A': UNDERGROUND STORAGE TANK PROGRAM =� 'moo Z. SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIO COMPLETE THIS FORM FOR EACH FACILITY/SITE �4OIF[R�tiP 77 ARK ONLY Elf NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ME I--� ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE is I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) C) FACILfTY/SITE NAk ^� CARE OF ADDRESS INFORMATION v v�A7 F/ 2 Z_ , U I`r// o ADDRESS ,'J e �On NE:ARESTCROSS STREET ✓Sox to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ,fy d �j/� (f„� -[.w /' /� ❑ CORPQRATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY C� G�'`- /L� ❑ tlNOIVIOUAL ❑ COUNTYAGENCY CITY NAME �•. l� `�� STATE ZIP SITEPHONE ,WITH AREA— DE TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR �FRROCEMR ✓Box if INDIAN EPA ID rF `V3 *,�y 9y/ RESERVATION or #of TANK's ❑ 1 GAS STATION ❑ 3 FARM Lv 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NA E(LAST,FIRST) PHONE#WITH AREA CODE DAYS, NAME(LAST,FIRST) PHONE II WITH AREA CODE �a 9-0q- y3-IFge sem• NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME,LAST,FIRST) PHONE#WITH AREA CODE C IL PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAMEZ-70 CARE OF ADDRESS INFORMATION L T- lz MAILING or STREET ADDRESS ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY y-NAF4Ii,•I� ElINDIVIDUAL ElCOUNTY-AGENCY CITY NAME � 5� STATE ZIP C©DE�� PHONE k,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION �W •v` Vim" - MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INCIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 0,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. Ev 11. ❑ 111.❑ 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 i COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE li [KEL�Lo l 6 611 0 CURRENT LOCAL AGENCY 4FAAC�ILITY 10# APPROVED BY NAME PHONE N WITH AREA CODE Y Y 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE O p Z � a �.0 YES ❑ NO 2-12- Q CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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. FORM A(3-2-88) E DATA PROCESSING COPY - vw�n rnvvcvy��w vvv .