BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAMA SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION '° `o G COMPLETE THIS FORM FOR EAC FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 1 AMENDED PERMIT •❑ 6 TEMPORARY SITE CLOSURE p� I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARL OF ADDRESS INFORMATION C/d o o Sorel .z/JC. ADDflESS �] �/ NEAREST CROSS STREET ✓IlmnNaraa 0 PARTMEA W 0 SIAIEAEF0 GD / � /—(!!�� 0 limmo�rM1N O fOATYA C ❑ FEDERAL AfiDC( CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE G Dt� CA asZ° (Zoq) 7/,,- 8`i4 TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ /PROCESSOR ✓Box it INDIAN EPA IO N ❑ 1 GASSTATION ❑3 FARM QSGTHER TTRUSTVLANDS or ❑ ATTHIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(UST,FIRST) PHONE N WITH AREA CODE DAYS. NAME ILAST,FIRST) PHONE N WITH AREA CODE 1,w�41L G�Lossa (& y66-�aQ NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFOHMAT ION /L( CidL 5ek 4 C MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP - 0 STATE AGENCY /� �J //!�F ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE M,WITH AREA CODE STdG To/✓ A- 4 Zb 20q) ZA/ - 84CT III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE Of ADDRESS INFORMATION ,tf_ C,ldGb fi So l L MAILING or STREET ADDRESS ✓Box to Ina,cala 0 PARTNERSHIP 0 STATE-AGENCY !. / 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL AGENCY 1q4 _7 L �`� 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE S oc t o C-4- 515 (zzt X166 £f9� IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOYB ADORLBf SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ if. III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICAN PS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 1 JURISDICTION 1 AGENCY B FACILITY ID If E of TANKS 11 SITE = = = D 1 C) I I I l I 8 Z O 1 D 1 O [-- CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE I WITH AREA COOS �lOS PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSU2SS TRAAC�T1F SUPERVISOR-D STRICT CODE BUSINESS PLAN FILED DATE f D O !J OV �� / YES NO � Z 5 CI I \ R CNECKI PERMIT AMOUNT SURCHARGEAMOUNT FEE CODE RECEIPT BY: S1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(MORE TANK PERMIT FORM 'B'APPLICATION(S), UNOTHIS ISA CHANGE OF SITE INFORMATION ONLY. O- FOHM�3-2-BB)