BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNO WATER RESOURCES CONTROROARD �a FORM A: W UNDERGROUND STORAGE TANK PROGRAM SITE 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 PEBU4NENTLY CLOSED ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE •4 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) DO FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION v () — 7),j hKi1 ADDRESS ��It �� NEST CR STREET INDIVIDUAL NATIO ❑ LOCAL AGENCY N ute 0 PARTNERSHIP 11 FEDERAAGEN {pY l ( fGENCY AAP10 OMTION ❑ COUNTY YAENp ❑ FEDERAL AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE 05- 20 6 —Z TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR -/Box if INDIAN EPA ID it ❑ 1 GAS STATION [:] 3 FARM ❑ 5 OTHER TRUSTVATION LANDS o ❑ AT THIS SITE ;2-, EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHO 4 WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE S n ' !� l� JS—if 6 —370o X/Z S v — 6f 3 0� y/ NIGHTS: NAME(LUT,FI 1L W/Vw PHONE 4 WITH AREA CODE NIGHTS. NAME LA T) PHONE p WITH AREA CODE I II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION EA57 Ay 1'x'1 UM. " es C-r MAILING or STREET ADDR S �'T ✓Box to Indicate ElPARTNERSHIP ❑ STATE-AGENCY I O 1 O L� OS CORPORATION LOCAL-AGENCY FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE KLerND GA 9 6z — di av y 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME /f CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to i,d,cate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,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. ❑ If. Ey 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED IS SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY N FACILITY ID AT It of TANKS at SITE 1 1010 1 6 1 1 1 D00 1 A CURRENT LOCAL AGENCY FACILITY ID# „/ APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE L'/•1,�/PERMIT EXPIRATIONibATE 112 LOCATION ODE Q ODE CENSUS TRACT# SUPERVISOR-DISTR�CODE BUSINESS PSN FILED NG ❑ DATE FILED 1 CHECK# jV' PERMIT AMOUNT SURCHARGE AMOUNT {�/] FEE CODE RECEIPT# BY: v 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. 1FORMA(3-2-88) (/� DATA PROCESSING COPY