Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD * <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM ;mo <br /> SITE i FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 0 o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ��.o.�. . <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) w <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION w <br /> h f `e3 w <br /> ADDRESS NEAREST CROSS STREET ✓ ❑ AWTMRw ❑ STAIE-AUND <br /> /Si/ f. iSl71 Piu m(7�� ❑ 1� 0 LInA-A"GBO ❑ FFBFNALAGEIIO' <br /> CITY NAME MIYAWO <br /> STATE ZIP CODE SITE PHONE Y,WITH AREA CODE <br /> CA 9 3 act <br /> TYPE OF BUSINESS: 0 2 NMWTOR E—] PROCESSOfl ✓Bac it INDIAN EPA ID Y <br /> ❑ I GAS STATION ❑3 FARM ❑5 OTHER TRUSTLANDS« ❑ I of TANK') <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE Y WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE A WITH AREA CODE <br /> a v ­7?0/ <br /> NIGHTS NAMEPAST•FIRST) PHONE/WITH AREA CODE NIGHTS. NAME LAST,FIRST <br /> ( 1 PHONE Y WITH AREA CODE <br /> S a - q 7 9- 333 i <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ckfa� T r urtries 112c - <br /> MAILING W STREET ADDRESS ✓Box la mmkwe ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE I.WITH AREA CODE <br /> dc) gYe �3v <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> as Si�C <br /> MAILING.STREET ADDRESS ✓SIM W""m ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ NTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE I,WITH MEA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE 11)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ If. ❑ IIL❑ <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 Y JURISDICTION F AGENCYIN FACILITY ID N Y OI TANKS al SITE <br /> mD 1 D / O i / D p o d <br /> CURRENT LOCAL AGENCY FACILITY 10 I APPROVED BY NAME PHONE F WITH MEA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LLOCATIONCO" CENSUS TRACT I SUPERVISOR-DISTRICT CODE BUSINESS PLM FILED DATE FILEDYES NO <br /> PERMIT MOUNT SURCHARGE AMOUNT FEE CODE RECEIPTS BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST )R MORE TANK PERMIT FO R M 'B'APPLICATION(S), t' 'S THIS IS A CHANGE OF SITE INFORMATI4ONLYY. <br /> FORM A(3-2-&B) <br /> L DATA PROCESSING COPY <br />