Laserfiche WebLink
++ee�.Trswr� <br />F_ <br />f <br />STATE OF CALIFORNIA, WATER RESOURCES CONTROL BOARD <br />.SEP H .. <br />FORM'A': <br />UNDERGROUND STORAGE TANK PROGRAM ry ^gym <br />SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONk!/ <br />fillMI-LC 1 C 1 HIS FORM rum EACH rACiLi I T/JI I E _4644� <br />MARK ONLY lv�1 NEW PERMIT F-] 3 RENEWAL PERMIT E 5 CHANGE OF INFORMATION 7 PERM ENTLY CLOSED SITE <br />ONE ITEM <br />El INTERIM PERMIT E714 AMENDED PERMIT 1:16 TEMPORARY SITE CLOSURE Il_J 1 / <br />I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />FACILITY/SITE N� <br />�iS ,2i 6uTiay, <br />CARE OF ADDRESS INFORMATION <br />ADDRESS ``` <br />6 i (J <br />A 6 <br />NEAREST GROSS STREET <br />✓ Bo mdicale ❑ PARTNERSHIP ❑ STATE -AGENCY <br />ORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL AGENCY <br />C/ //// <br />J/�/" !// <br />INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME � J _ / �v � <br />STATE <br />ZIP C0� � � <br />9 - <br />SITE PHONE #, WITH AREA CODE / <br />I <br />STATEZIP <br />fit! ❑1 <br />CODE <br />0 7:�QZ_ <br />PHONE #, WI H AREA CODE <br />1.09 6 S-1- <br />TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 OCESSOR <br />✓ Box if INDIAN <br />RESERVATION or <br />EPA ID # <br /># of TANK's 0 <br />1 GAS STATION ❑ 3 FARM 5 OTHER <br />TRUST LANDS ❑ <br />AT THIS SITE <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYSNAME (LAST, FIRST) PHONE It WITH AREA CODE <br />Z-kGv M'r ke Zo Gi-�/� s = �`i f <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />/z >� e�Nok i- <br />NIGHTS:. NAME ( ST, FIRST) PHONE # WITH AREA CODE <br />Lt e� C(e 12 <br />NIGHTS: NAME (LAST, I T) PHONE # WITH AREA ODE <br />�J�� / Z <br />M I Z� - - <br />u, I- . 2a - <br />II. PROPERTY 6WNER INFORMATION & ADDRESS — (MUST BE COMPL&ED) <br />NAME //j"�' ' I <br />IQ� UD i <br />114"Ir <br />i r <br />E OF ADDRESS INFORMATION <br />MAILING or STREET A R S c <br />C <br />f <br />C., <br />✓ -'0indicate <br />CORPORATION <br />INDIVIDUAL <br />❑ PARTNERSHIP ElSTATE-AGENCY <br />❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />❑ COUNTY -AGENCY <br />CITY NAME <br />APPROVED BY NAME PHONE If WITH AREA CODE <br />STATEZIP <br />fit! ❑1 <br />CODE <br />0 7:�QZ_ <br />PHONE #, WI H AREA CODE <br />III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />NAME CARE OF ADDRESS INFORMATION <br />MAILING or STREET DDRESSA /� x to indicate El PARTNERSHIP ❑ STATE -AGENCY <br />ill /S� CORPORATION ElLOCAL-AGENCY ❑ FEDERAL -AGENCY <br />PJ V 1. ❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME STATE ZIP CODE PHONE #. WAREA CODE <br />s- 'I �S�i 6 -VA -1-q S'/-3 ( Z/ �e.-Y32-Md <br />IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br />CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />APPLICANT'S NAME (PRINTED & SIGNATURE) DATE <br />LOCAL AGENCY USE ONLY <br />COUNTY # <br />JURISDICTION If <br />AGENCY # <br />FACILITY ID # <br /># of TANKS at SITElam' <br />C., <br />Ltl')f <br />/ 101 A 10 k:2 / <br />CURRENT LOCAL AGENCY FACILITY ID # <br />APPROVED BY NAME PHONE If WITH AREA CODE <br />PERMIT NUMBER <br />PERMIT A PROVALnAlE / <br />j G <br />r <br />PERMIT EXPIRATION DATE <br />/, 0 <br />LOCATION CODE <br />CENSUS TRACT # <br />SUPERVISOR -DISTRICT C E <br />BUSINESS PLAN FILED <br />DATE FILED <br />O <br />% <br />YES NO <br />CHECK # <br />PERMIT AMOUNT <br />SURCHARGE AMOUNT <br />FEE CODE <br />RECEIPT # <br />BY: <br />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. <br />FORMA (3-2-88) <br />DATA PROCESSING COPY <br />rV <br />t'V <br />00 <br />