BILLING - Laserfiche WebLink

Home Browse Search

IPSTATE OF CALIFORN WATERESOURCES CONTROL BOARD FORM `A': UNDERGROUND ST RAGE TANK PROGRAM �` �o A SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -� COMPLETE THIS FORM FOR EACH FACILITY/SITE C�lIFORN P F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE MARK ONLY F-1 1 NEW PERMIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE a) I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) W FACILITY/SITE NAM CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Box to indicate El PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME '-s/ �_'� STATCA ZIP CODE SITE PHONE#.WITH AREA CODE TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK's 5 OTHER RESERVATION or ❑ AT THIS SITE ❑ 1 GAS STATION ❑ 3 FARM ❑ TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CC DE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ElSTATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE#,WITH AREA CODE CITY NAME III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME MAILING or STREET ADDRESS ✓Box to indicate [3 PARTNERSHIP ElSTATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE#,WITH AREA CODE CITY NAME IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WNICN 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 10# #of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION 900E CENSUS TRACT SUPERVISOD R-( STRICT CDOE BUSINESS PLAN FILED DATE FI Er 1 fl CI YES ❑ NO ❑ I JRECEIPT# BY: CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE \\ TIJUS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMI ORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. ` �ORN A(3-2-88) • �JDATA P OCESSING COPY