Laserfiche WebLink
STATE OF CALIFORNI# WATER RESOURCES CONTR(s1cBOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ®7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE C) <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) p <br /> FACILITY/SITE NAME CARE FADDRESS INFO TI N <br /> olis D + <br /> ADDRESS NEAREST CROSS STREET <br /> . El PNNBBHIP 11 STATE1RDO✓ oOc ❑ RmwACBc2017 UAUetj 0 NDYN& COUNWACBl <br /> CITY NAME STATE ZIP CODE Sly PHOtIE N,WITH AREA;CODE <br /> CA 2OS oq 9 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Bax N INDIAN EPA 10 N B of TANK'S <br /> E]1 GAS STATION ❑3 FARM 5 OTHER TRUSTVLA ION Vr ❑ N AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAM (IAST.FIRST) PHONE N WITH AREA CODE <br /> I' LA0 6'2-/ yq k, <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE n 1, <br /> oft CM Z Z - N <br /> II. PROPERTY OWNER INFORMATIO &AD SS— (MUST BE COMPLETED) <br /> NAMEt, 'tom Agil )• F CARE OF ADDRESS INFOflMATION <br /> MAILING or STREET ADDRESS v ✓Box to indicale 0 PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRES — (MUST BE COMPLETED) <br /> NAM)i�� CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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: 1. 011. ❑ IS.❑ <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# JURISDICTION If AGENCY N FACILITY ID N If of TANKS at SITE <br /> 10 10 b ,15 60) 10 <br /> CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE N W ITN AREA CODE <br /> 01-1 s ,2 D <br /> PERMIT NUMBER PERMIT APPROVAL DATED PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TMCT N SUPERVISCIR-O'NITR1CT CODE BUSINESS PUN FILED PATE FI ED <br /> 3 Z YES ❑ NO ❑ /1 6� <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST I"OR MORE TANK PERMIT FORM'B'APPLICATION(S), UNI ESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> �" Y S <br /> DATA PROCESSING COPY <br />