BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': - °° UNDERGROUND STORAGE TANK PROGRAM SITE C° FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONfn COMPLETE THIS FORM FOR EACH FACILITY/SITE °q�Foa-"-'" 4 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANEN E N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT u 6 TEMPORARY SITE CLOSURE .... I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRES5_INFORMATION &ALID L) ADDRESS^^ NEAREST CROSS STREET �✓ByTloMute ❑ PARTNERSHIP ❑ STATE-AGENCY 1)W E �lw I �,r San- _ e CD _ E] INDIVIDUAL ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY J(i �h ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE Loaf CA 9 4 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box ii INDIAN EPA ID # ❑ ❑ TRUSTVATION LANDS or ❑ AT HIS SITE 1 GAS STATION 3 FARM 5 OTHER AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE 1004pKlos, 00000A (,AW) 3Coa - 31.34 MA-ReETi I I f�60 (Xq) (o�3-os37 NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE It WITH AREA CODE -TCrA19ILIOS t)oi A3A (260 333 - I010 HAfLQE TTI poi: (-t) 381 -a-74 I II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION (XLTQAmvAQ I►)c SAI)Dy H(Apf- MAILING or STREET ADDRESS ✓fox to indicate ElPARTNERSHIP ❑ STATE-AGENCY 5�S (� fn JT E] CORPORATION 1-1LOCAL-AGENCY ElFEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE AIJ�roeo & q`3 a3a (abs) s8-,- < Swg III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION ULZeAmA2 IN C„ AN)Wi OLA:_r MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY CK CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STTE ZIP CODE PHONE#,WITH AREA CODE n�F I}Ro2w uA (�0`9) s83-s5G8 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. N III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATUREh DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE [m I I I j I I I 1 1010-11 / I,? 1</' L�16b_Tl_ CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE S jF0 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT IFILED _ 9 3 QQ YES NO 11 \ CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE __FRECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MnRE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THI^"'A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) C DATA PROCESSING COPY w - i