BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNAP WATER RESOURCES CONTR BOARD UNDERGROUND STORAGE TANK PROGRAM SITE oC. FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° �: o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 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 ,,�J✓�� I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILI BI-E NAMEDQ h ' /!�� CA OF ADDRESS IyFf1RMATl N ADDRESS NEARISTCRO SSTREET ✓BORN nk0 PAATNEASHIP ❑ STATE AGENCY b ^ I/J1 ❑ WIPIDUAL 0 LOUNTYAGENY ❑ FEDERAL-AGENCY fN�v. 0 INDIVIDUAL 0 07UNIVAGENCY CITY ME L STATE CE SITE PH NE p,WITH AREA CODE TYPE OF BUSINESS: ❑ 2DISTRIBUTOR ❑ 4PROCESSOR ✓Box if INDIAN EPA ID a Not TANK's F-1I GAS STATION ❑3 FARM F1 5 OTHER TRUSTMLAND$or ❑ elokWolrC AT THIS SITE 0 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DA NAM ST,FIRST) PHONE N WITH AREA CODE DAYS: N ME(LAST,FIRST) ANE N WITH AREA CODE �36N-I I r j\j//� NIGHTS: NAME(IA FIRST) PNE#WITH AREA CODE NIGH AME(LAST,FIRST) P NE#WITH AREA CODE 16 A II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) rZ,IjA^/ gJ //. 4� 444 ,, D/ CA OF ADDRESS ORM TION MAILING or STREETADORESS ✓Box indicate PARTNERSHIP 0 STATE-AGENCY 7 Jr 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY In ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME ST E ZIP CODE I PHONEI,W H AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED)) L3 NAME CARE OF ADDRESS INFORMATION MAILING rSTREETADDRESS ✓Box to,.d,cale 0 PARTNERSHIP ❑ STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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: 1. ❑ IL 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 S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY IDN N of TANKS at SITE (�] D o l o CU E TLOCALAGENCY FACILITY IDN APPPR''VVED BY A ��y��` PHONE N WITH AREA CODE (J 2 / c� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK# E CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED A � /� YES � NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST#OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-OB) DATA PROCESSING COPY