BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORWS & o. WATER RESOURCES CONTR OARD s FORM `A': 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 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 51 — W I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) CD A FACILI /SITE NAME CARE OF ADDRESS INFORMATION j i e- t0ctwl Lou IS Pear k l�G ,v-% ADDRESS NEAREST CROSS STREET ✓Bo.lardoile D PA ERSHIP D SiAiE AGENCY D CGRPODCAL-AGENCY D FEDERAL AGENCY leS (i D INDMOUAL D CDUNIY AGENCY CITY NAME n STATE ZIP CODE SITE PHONE a,WITH AREA CODE CAS l TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓BOx if INDIAN EPA ID # #01 TANK'# ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUSTYATION LANDS Or ❑ AT THIS SITE UU EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE rte. �ci� IlaT, aaggq-jx3,41 NIGHTS. NAME(LAS11,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAN/ 1ii (; J,ll� CARE OF AO RESS INFORMATION .l MAILING or STPIEET ADDRESS ✓Box to indicate D P NERSHIP D STATE-AGENCY 1r/��1 ^/ _` D CORPORATION AL-AGENCY D FEDERAL-AGENCY S I 4✓0Y l�7�X_J D INDIVIDUAL COUNTY-AGENCY CITY NAME ST ZIP DE PHONE#.WITH AREA CODE 5foa+vq � Sada III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY ❑ FEDERAL-AGENCY D INDIVIDUAL D COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CNECK ONE(t)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: If. 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 L LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If AGENCY# FACILITY ID# M o1 TANKS at SITE a 3 S CURRENT LOCAL AGENCYF/LCILITY IID 0 APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER ((') PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUSTRACT# SUPERVISORAISICT CODE BUSINES,PSNFILED NO ❑ DIT ED CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: (,/1, 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