Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': e � <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE <br /> MARK ONLY Ww NEW PERMIT ❑ 3 RENEWAL PERMIT IV5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE LI <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Frank C. Alegre Trucking, Inc, fCJi <br /> ADDRESS NEAREST CROSS STREET VadatMrYe 13FAARIERSHIP D STATE AGENCY `v <br /> 802 N. Cluff Turner Rd ❑ IxorvDunm D Gu�xry cxc 13 <br /> ` M(��"� <br /> CITY NAME STATE ZIP CODE SITE PHONE a,WITH AREA CODE <br /> Lodi CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID a <br /> ION 3 FARM X 5 OTHER RESERVATION or #of TANK't <br /> E] i GPS STAT ❑❑ TRUST LANDS ❑ CAC 000272655 AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> Robert Fowler 209 3-14-1-12 <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) % P0Q) <br /> E p WITH AREA CODE <br /> Robert Fowler <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Frank C. Alegre Inlicking TnC <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP El STATE-AGENCY <br /> 802 hl. C.11iffCORPORATION Cl LOCAL-AGENCY O FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> 334-2.117 <br /> Ill. <br /> 3 - <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box la intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 802 N_ $CORPORATION CILOCAL-AGENCY11 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 13 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> Lodi <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: 1. ® 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 /> r4alejee e. 1 10-26-90 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION M AGENCY R FACILITY ID# #of TANKS at SITE <br /> 3 12 <br /> CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE#WITH AREA CODE <br /> LE6AE' o <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUUS TRA�CT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3. <br /> CHECK# PERMIT SURCHARGE AMOUNT FEE CODE YES [j NO <br /> ❑ BY: 90 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(SL UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> ORM A(3-2-BG) <br /> \\ —a� —C\ DATA PROCESSING COPY <br />