BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD °:u,`F FORM IA': UNDERGROUND STORAGE TANK PROGRAM =y �m SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH F CILITY/SITE `^<,.or,��" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PENENTLY CLOSED SITE I"a ONE ITEM ❑p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE _N! I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) N FV FACILITY/SITE NAM CARE OF ADDRESS INFORMATION ADDRESS 7,f ' ` NEAREST CROSS STREET ✓Bw tO 1 11 PARTNERSHIP 13 STATE AGENCY '(/p 2,101 (/V Qo db/1(� d Afy El CORPORATION 1:1 LOCA-AGENCY 13FEDERALAGENCY F' ❑ INDIVIDUAL ❑ COUNTYAGENCY CITU NAME ISTATE ZIP C E SITE PIJO E#,WITH AREA CODE 0 CA TYPE OF BUSINESS. p IBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA IO # ❑ I GAS STATION 3 FARM ❑ 5 OTHER TRUSTVLANDS ATION�r ❑ #of HIS SITE AT THIS STE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: N"�AAME ILA T.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE tJ � IC NIGHTS: NAME(LAST,F ST) 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 lntlicate Cl PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME [ CARE OF ADDRESS INFORMATION �s MAILING or STREET ADDRESS ✓Bax Io lntlicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE If,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. II. ❑ 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 Is AGENCY# FACILITY ID# #of TANKS at SITE 1 0 1171 101016117-1 CURRENT LOCAL AGENCY FA�1 10# _ V APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER `�fL- oP`/E'RMMIIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT k SUPERVISOR-DI$7T CODE BUSINESS PLAN FILED DATE FILED /, p l/{�G(1/1 YES [] NO 6—l7_p 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 ONLY. FORMA(3-2-88) DATA PROCESSING COPY