Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD '` '' <br /> FORM A : UNDERGROUND STORAGE TANK PROGRAM ' o <br /> S�T FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> CCOMPLETE THIS FORM FOR EACH FACILITY/SITE °'a FueGx`r <br /> MARK ONLY 1 NEWPERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PER NTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 0 / z <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) 16 <br /> FACILITY/SITENAME C)&r III CARE OF ADDRESS INFORMATION <br /> Sil Aoseoklsial <br /> ADDRESS NEAREST CROSS STREET ✓ h4cele ❑ PARTNERSHP D FAIEAGm N <br /> p(5/ D Ca ' ✓1 ' .,l ,p 0]RPDRATON D LOCAL.AGENCY D FEOIXAI.AGENpco <br /> - n r W or G.r ❑ INDMWAL o COU I AGENCY <br /> CITY NAME • ��� STATE ZIPCODE ITE PHON II EA CODE <br /> CA �o ao M216 30(, <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 P CESSOR ✓Boz A INDIAN EPA ID N <br /> RESERVATION or /I J x of TANK'S t <br /> ❑ I GAS STATION ❑ 3FARM OTHER TRUST LANDS ❑ NQ /V AT THIS SITE I <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Oe - a - ao a >✓ a3010 <br /> NIGHTS: ME(LAST,FI ) PH NE k WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> u)crEn ' neer a - <br /> 11. PROPERTY OWNth INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME C c ) 4 I CARE OF ADDRESS INFORMATION <br /> I J <br /> MAILING or STREET ADDRESS I ✓ao(to i"dicete 11 PARTNERSHIP 11STATE-AGENCY <br /> l (�+� ORPORATION D LOCALAGENCYD FEDERAL-AGENCY <br /> .J I ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> S C 4-cy� Ao9 9v3-a00049x <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> <S Q a S ert <br /> MAILING or STREET ADDRESS ©)il ✓ xio indicate D PARTNERSHIP D STATE-AGENCY <br /> LWI/ CORPORATION D LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <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. ❑ 111 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 N JURISDICTION K AGENCY R FACILITY ID N N of TANKS at SITE <br /> d0 0 <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE M WITH AREA CODE <br /> S <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXP) TIONDATE <br /> 00/ 037 --a1— eol> E7 <br /> 3l- <br /> LOCATION CODE CEN�SS"TTUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> OA 3 , �D YES NO g a 9 0 <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTF 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 INFORMA4ONL <br /> 1 FORMA(3-2-88) <br /> DATA PROCESSING COPY -'� <br />