Laserfiche WebLink
STATE OF CALIFORNIt,r WATER RESOURCES CONTROebOARD <br /> f f <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �e Z <br /> SITE} FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to <br /> II COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ANENTLY CLOSED SITE CA) <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Q1w'f` <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N <br /> A <br /> FACILITY/SITE NAME9 s�, CARE OF ADDRESS INFORMATION <br /> (S IN <br /> ADDRESS 3 NEAREST CROSS STREET ✓B iixj k ❑ PARTNERSHIP ❑ STATEAGENCY' <br /> ST RPW PON ❑ LOCAL ❑ EEDEULAGENCY <br /> INOIVINAL Cl COUNTY-AGENCY <br /> CITY NAME ��� STATE ZIP CODE SITE PHONE tl,WITH AREA CODE <br /> yy 20 6 6 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a If of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSRESETVLANDS ATION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) R� PHONE#WITH AREA CODE DAYS. NAME LAST,FIRST) PHONE 0 WITH AREA CODE <br /> (/:Ni <br /> NIGHTS: NAME(LAST,FIRST) HONE p WITH AREA CODE NIGHTS. NAME(LA ,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 6&w 11 <br /> MAILING or ST$EET ADDRESS ox'.i.di T.te ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 6 F7 C <br /> VORPORATION LOCAL-AGENCY ClFEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATEZIP CODE PHONE N.WITH AREA CODE <br /> F u5� 0 <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAMErJ � CARE OF ADD R S INFORMATION <br /> a� S a o o�v S cGL�-� <br /> v <br /> MAILING or STREET ADDRESS Bo mdicale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> INDIVIDUAL <br /> ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> INDIVIDUAL ❑ LOCAL-AGENCY <br /> COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONEI 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: C ❑ 11. ❑ 111. <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 11 JURISDICTION R AGENCY M FACILITY ID k R of TANKS of SITE <br /> ME = = lololAal3clolo <br /> CURRENT LOCAL AGENCY FACILITY ID If, APPROVED B N E PHONE N WITH AREA CODE <br /> r,AevR / <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> /ozyQ47 <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Oj ? R 71-6 YES ❑ NO <br /> CHECK* PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM BY APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> -\ IRMA(3-2-88), <br /> � DATA PROCESSING COPY `,( <br />