Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> SIFORMT IA''r UNDERGROUND STORAGE TANK PROGRAM ®; <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION l o <br /> m . . <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEN!PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY QLOS,5D SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT El 1:1 AMENDED PERMIT 1:16 TEMPORARY SITE CLOSURE G'av <br /> N <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) -4 <br /> O <br /> FACIU /SITE AME ` CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓aNxim Cl PANfNEIEHP C STATEAGOV <br /> Cl CONOM11ON Cl LOCAL WOO C FOM AGDCY <br /> Cl iNOMCUAL Cl WM1tt-AC0CY <br /> CITY NAME STATE ZI CODE SITE PHONE P.WITH AREA CODE <br /> CA ,'V6S <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 7 d P p R ✓Box if INDIAN EPA ID <br /> E] I=I/ RESERVATION ar ❑ - Sol TANIh <br /> ❑ 1 GAS STATION ❑3 FARM I. Lam, o OTHEfl TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT RSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE <br /> NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS- NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓80x m ird,cme C PARTNERSHIP C STATE-AGENCY <br /> C CORPORATION Cl LOCAL-AGENCY C FEDERAL-AGENCY <br /> C INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> II <br /> ' <br /> III. TANK OWNER INFORMATION & ADDRESS (MUST BE COMPLETED) <br /> NAME\ CARE OF ADDRESS INFORMATION <br /> MAILING Or STREET ADDRESS \ ✓BOx to Indicate C PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION C LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> Cl INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME �, STATE ZIP CODE PHONE A,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING INNICH ABOVB ADDRBS SHOULD BE USED FOR BOTN\bEGAL NOTIFICATION AND BILLING: L ❑ II. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO E BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY S JURISDICTION Al AGENCYA, FACILITY ID S •of TANKS at SITE <br /> OdaaS 5:( O Doo <br /> CURRENT L AGE CY FACILITY ID S APPROVED BY NAME PHONE S WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA ON CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN PILED OATEFl D <br /> 3, a YES NO 1f <br /> CHECK Y PERMIT AMOUNT SURCHARGE AMO NT FEE CODE RECEIPT a SY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPUCATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />