BILLING - Laserfiche WebLink

Home Browse Search

� . STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE a^"" MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT Rr5 CHANGE OF INFORMATION ❑ 7 PE LY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Z I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 10 FACILITY TE NAME J� CARE OF ADDRESS INFORMATION ADDRESS // -/ C NEAREST CROSS STREET ✓Bab MrY ❑ PAITTREMW El STATE AGENCY N 3( '7�7S o LOAPpUTDN ❑ U1CII.AMC o FpEMLAGFNCY 00 J L !lW D INDVIWIA ❑ Cwm-AGENCY (D CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE W CA TYPE OF BUSINESS: ❑2(NSTRIBUTOR ❑/PROCESSOR ✓Box d INDIAN EPA ID X RESERVATION or #of TAN 's ❑ I GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS', NAME(UST.FIRST) PHONE X WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE X.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toiw"ie ❑ PARTNERSHIPP ❑ STATE-AGENCY ❑ CORPORATION 0 LOCAL AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL Cl COUNTYAGENCY CITY NAME STATE DECODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE 6G i G l e2 D o o '717,;37'9 URRENT LOCK A ENC!FACILITY 10 R APPROVED BY NAME PHONE#WITH AREA CODE �uNi9 7 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO ❑ /N� /0// CHECKS 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. d�