BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORA WATER RESOURCES CONT BOARD ` FORMW:: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PE ENTLY 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 N / _ CARE OF ADDRESS INFORMATION Do ADDRESS NEAREST CROS STREET B.to irdolle ❑ PARRIER�TIIP ❑ STATE AGENp ❑ COFFORATION ❑ LOC&AGENCY ❑ FEDEML AGExp IN aS ❑ INgV1g1Al ❑ WUx1V AGENCY CIN NAME ��f V STATE ZIP CODE '7 SITE PHONE N.WITH AREA CODE CA ��J TYPE OF BUSINESS. ❑2 DISTRIBUTOR ❑ 4 WESSOR ✓Box if INDIAN EPA ID N #of TANK's RESERVATION or ❑ AT THIS SITE ❑ I GAS STATION ❑ 3 FARM S 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 N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION IN e MAILING or STREET ADDRESS x Lo indicate ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS NY'Box loindicale ❑ PARTNERSHIP ❑ STATE-AGENCY nn ❑ CORPORATION D LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE N,WITH AREA CODE COV NAME � � � IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 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 M JURISDICTION M AGENCYIII FACILITY ID R N of TANKS at SITE " CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE cy//� /g LOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES ❑ NO ❑ 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 Y. FORM A(3-2-88)