BILLING - Laserfiche WebLink

Home Browse Search

n'PN,"T'"�P,''S'^yi.��q„yrP.l.., . ,,.,.,.4.,n. .,e—... ,.,�y,��eF".n.nn..m'nn-••.,.a. y . . STATE OF CALIFORNh WATER RESOURCES CONTROL ARD FORM `Ay: ° .. UNDERGROUND STORAGE TANK PROGRAMo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE �!.oaN.o• A MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLEDD SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 6 / �. 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) 41-W j✓- _ FACILITY/SITE NAME "� /+ CARE OFA ESS INFORMATION ADDRESS NEAREST CROSS STREET -/S.10,161 ❑ PARTNERSHIP ❑ STAFE-AGENCY 3 El CORPORATION ❑ LOCALAGENCY ❑ FEDERAL�, ',,l ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME { STATE ZIP CODE SITE PHONE A.WITH AREA CODE lam/ CA NQS— - 2395-- TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a so TANK's ❑ 1 GASSTATION ❑3 FARM ❑ 5 OTHER TRUSRYLANDS ATION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS'. NAME(I-AST,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 ADS fFORMAJLON l G MAILING or STREET ADORESS ✓Box to,ndioate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY JI �S ❑ INDIVIDUAL ❑ COUNTY-AGENCY CIA 7 STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAM CARE OF ADDRESS INFORMATION CiS MAILING or STREET ADDRESS ✓Box to iooicate C PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERALAGENCY 0 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p.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: L ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 4f JURISDICTION Ar AGENCY# GLLTY.10p pot TANKS a1 SITE AL3 ,3f�. CURRENT L CY FACILITY ID p APPROVED BY NAME PHONE#WITH AREA CODE 1 PERMIT NUMBER VAL DATE PERMIT EXPIRATION DATE LCHECK* ODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FI D 32� VES NO D PERMIT A CUNT SURCHARGE AMOUNT FEE CODE RECEIPTp BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MOR NK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL FORMA(3-2-88) * \�� DATA PROCESSING COPY •