Laserfiche WebLink
STATE OF CALIFORNIP WATER RESOURCES CONTROL'BOARD <br /> FORM IA': <br /> r. <br /> SITE UNDERGROUND STORAGE TANK PROGRAM <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `^ ," 1 O <br /> MARK ONLY ❑ 1 NEW PERMIT [:] 3 RENEWAL PERMIT <br /> ONE ITEM 5 CHANGE OF INFORMATION E�j7 PERMANENTLY CLOSED SITE Fi <br /> 2 INTERIM PERMIT 0 q AMENDED PERMIT <br /> 6 TEMPORARY SITE CLOSURE �!\ (a <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 11 C <br /> FACILITY/ ITS NAME co <br /> V ((•J lie 1 1-e' CARE OF'- DARES I"ORMATI M <br /> ZL <br /> ADDRESS C <br /> u`l In n (b NEAREST CROSS STREET ✓goy 10i Iimle ❑ PARTNERSHIP 13STATEAGENCI <br /> CITY E CORPORATION ❑ LOCAL AGENCY Cl FEDERAL AGI <br /> El 520 <br /> 13COUNTYAGEND <br /> STATE ZIP CODE SITE PHONE ,WITH A <br /> TYPE OF BUSINESS: p DISTRIBUTOR q PROCESSOR ✓Box it INDIAN EPA D ft IE <br /> 5 z o 5 pAREA CODE <br /> CA <br /> O 9 y(P t <br /> I GAS STATION 3 FARM 5 OTHER RESERVATION or ❑ - p of TANK' <br /> TRUSTLANDS sO <br /> EMERGENCY CONTACT PERSON(PRIMARY) AT THIS SITE <br /> EMERGENCY CONTACT PERSON(S <br /> DAYS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST, ECONDARY)FIRS�� <br /> r PHONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST,FI 7) PHONE p WITH AREA CODE NIGHTS. NAME(LAST,FIRST) <br /> PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME � J <br /> 1 � I� <br /> In CARE OF ADDRESS INFORMATION <br /> MAILING.,STREET ADDRESS ISA n <br /> /Box to intlicalE e ❑ PARTNERSHIP ❑'STAT <br /> S . �LOR( �I ORATION ❑ LOCAL-AGENCY 7 AGENCY <br /> CITY NAME p�INDIVIAGENCY <br /> ❑ COUNTY- FEDERAL-AGENCY <br /> �L STA ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED)�a <br /> NAME <br /> OFA RESS INFORMATION ` <br /> MAILING or STREET ADD ESS L-(QWA <br /> ,✓9exto intlicale ❑ PARTNtRSHIP ❑ STATEAGENCYv� 4C CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCYCITY NAME __ ' ` ) ❑ WDIVIDUAL ❑ COUNT'- <br /> �,�"�[_JVY AGENCY <br /> STAT PHONE p,WITH AREA CODE <br /> ZIP n <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS a,O oZ(39 `i(o p I N P <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MV KNOWLEDGE, IS TRUE ANDD CORRECT <br /> APPLICANT'S NAME(PRINTED 851GNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# <br /> FACILITY ID# #of TANKS at SITE <br /> 3d <br /> 3 � <br /> CURpENT LOCAL AGENCY FACILITY ID p <br /> APPROVED BY NAME PHONE p WITH AREA CODE <br /> �1 L_Lr= <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> LOCATIONCODE CENSUS RACT#O SUPERVISSOI-DISTRICT CODE BUSINESS PLAN FILED <br /> 3 V cb DATE FILED M <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE YES NO A..l I }�{ <br /> RECEIPT# CLO <br /> 1 Cll <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM IS'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> 0 DATA PROCESSING COPY 0 <br />