BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFOFRIA WATER RESOURCES CON i5`a� k,-.rF OL BOARD FORMW: : =y UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE ` _Forty'° MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM INTERIM PERMIT ❑ 4 AMENDEO PERMIT ❑ 8 TEMPORARY SITE CLOSURE p I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 10 FACILITY/SITE NAME _ CAPE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STRE T �✓ IoinOieele ❑ PARTNERSHIP ❑ STATE AGENCY ,jf� Q //��r 13COR=PA IN Q LOCAL-AGENCY ❑ FEDFRAL-AGENCY CTI / u '^' o 4- ` ,U ❑ INDIVIDUAL ❑ COUNTY-AGENCYCITY NAME to STAT ZIP CODE SITE PHONE#,WITH AREA CODE N d C � CA C� ok 7(ra TYPE OF BUSINESS: ❑ pISTR18Ui0R ❑ 4 PROCESSOR '/Rox it dNDIAN EPA ID # ❑ 1 GAS STATION ❑ 3 FARM E] 5 OTHER TRUSTTLANDS or ❑ 0 On e— AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Lewis- (,Fa l) ,A `??- 303&, m i C1e ScA !d-ml i e r—&16)33 .5416 NIGHTS: NAME(LAST,F• 1 I�R,S�ITr)� PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE �� i SSC e— ll. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION ` r , I_ r p Qrii Lin 411 Pn a e-r l' e me-;n 7` MAPIC) , G or STREET ADDRESS rWt1 ,.✓ to indicate ❑ PARTIi SHfP STATE-AGENCY O( ©� i L'IrCORPORATION Q LOCAL-AGENCY ❑ FEDERAL-AGENCY ff ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STAT ZIP CODE PHONE#.WITH AREA CODE Flo n F50*7a -a0 (GDA) 53-q&60 III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) '" �/a5 NAME CARE OF ADDRESS INFORMATION rc, ! r air a41fn , u f MAILING or STREET ADDRESS ,.,✓ to indicate Q PARTNERSHIP IJSTATE-AGENCY ` L"S CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY I �/ C . Q INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME KD 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: I. ❑ 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 B SIGNATURE) DATE LOCAL AGENCY USE ONLY FCHECK# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE Efl I I I I RoIo / 7 AGENCY FACILITY ID# APP O BY NAME PHONE#WITH AREA CODE r , PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CENSUS TRACT# SU RVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED f YES ❑ NO ❑ PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) DATA PROCESSING COPY