BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIAO WATER RESOURCES CONTRO OARD A �1 FORM 1A': UNDERGROUND STORAGE TANK PROGRAM =" SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION $efy/m e M E Cutrt ADDRESS NEAREST CROSS STREET ✓Bwtri D PARTNERSHIP D STATE AGENCY + f D CORPORATION D UOCALA ❑ PEOE1uAGENCY SN D INDIVIDUAL D COUNTY AGENCY CITY NAqA( STATE ZIP CODE SITE PHONE#,`KITH AREA CODE S� kFo� CA Qs�z 2o? "(/Gii� TYPE OF BUSINESS: 2 DISTRIBUTOR ❑/PROCESSOR ✓Box if INDIAN EPA ID If k of TANK'# RESERVATION or AT THIS SITE ❑ 1 GASSTATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE n2leM.s. �-ydf�-83// ,$fswe NIGHT$: NAM (LAST.FIRST) PHONE#WITH AREA CODE NIGHTS NAME(VAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME _ CARE OF ADDRESS INFORMATION U/ &" cY .SP f/lC.�e MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY N �/ /(jl•(' D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CIN NAME STATE ZIP CODE PHONE If,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CAREOFADDRES i OORMATION r l of .SPrdk c M� 14 of MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY �O D CORPORATION D LOCAL-AGENCY ❑ FE AL-AGENCY J D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITHAREA CODE c0��c 's likr / 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 S JURISDICTION M AGENCY R FACILITY ID M k of TANKS N SITE " CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE M WITH AREA CODE W PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT P SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED NO ❑ DATE' � fLE C 2� 9 325— // CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY, p S SOl 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) 0 0