BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL IARD FORM A: UNDERGROUND STORAGE TANK PROGRAM No z FMARKFACILITY/SITE, INFORMATION anCOMPLETE THIS FORM FOR EACH F CILITY/SITEONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMAN SED SITE I"A. ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 IU I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION rf I ADDRESS NEAREST CROSS STR ET ✓Boxto v4i�te ❑ PARTNERSHIP ❑ STATE AGENCY ^ . ❑ CA TION 0 LOCALAGENCY 0 FEDERA.AGENCY I� D O S DNIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE ITE PHONE#,WITH AREA CODE CAab g 38— 5 TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ It PROCESSOR ✓Box,f INDIAN EPA ID # #of TANK's F-11 GAS STATION J FARM F—] 5 OTHER TRUSTYATION LANDS o ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(I-AST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(IAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME � p CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME S —,y^ CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to,,doate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL Cl 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. it. ❑ 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 COODUN�(TAY#�� JURISDICTION# AGENCY# FACILI # #of TANKS at SITE APPROVED BY NA / PHONE#WITH AREA CODE CURRENT LOCAL AGENCY FACILITY ID �A „ ^��j� PERMIT NUMBER PERMIT AP ATE PERMIT EXPIRATION DATE LOCATjQN CODE CENSUS TRACZM SUPERVI CRSI8TRICT CODE BUSINESS PLAN FILED DATE FILED `TIS RC1 YES NO CHEC # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE flECEIPTp Y: \\\ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'S'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) \\V DATA PROCESSING COPY