Laserfiche WebLink
1 <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM = ° <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION '° 2 <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE `'��roer•`" 10 <br /> MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION ❑7 PERMANENTLY LOSED SITE FV <br /> ONE ITEM ❑ Z INTERIM PERMIT ❑ 4 AMENDED PERMIT El6 TEMPORARY SITE CLOSURE L <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/BITE NAME / CARE OF ADDRESS INFORMATION <br /> ADDRESS M/ NEAREST CROSS STREET ✓ woJI ❑ PARINESSWP ❑ STATE AGEN,Y <br /> ? /r _ 00WOVTON ❑ LXALAGDO ❑ FEDEIUL.AGEMX <br /> J ��EF'' ❑ INCMWN ❑ WUNTY-AGENCY <br /> CITY N E STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> /1G �D✓ CA <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑4 PflOCESSOR ✓BOX B INDIAN EPA ID n <br /> RESERVATION w #of TANKS <br /> ❑ 1 GAS STATION ❑ 3 FARM �5 OTHER TRUST LANDS ❑ AT THIS SITE J <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 /> z 0 '2ay- G- ero o <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 7 A ?d�1 4,i L -/, <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> (rxb J J we-le - Z <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ RPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> CITY NAM ' _ STATE INDIVIDUAL ZIPCOD❑ COUNTY-AGE#PHONE#,WITH AREA CODE <br /> 0 o,J <br /> CAL <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME p� CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓pgox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> IE'CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 3 LIQ ZN ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU N E STATE ZIP CODE PHONE N,WITH AREA CODE <br /> oc oA/ <br /> 91cm -300-3 <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. lz it. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> NAME(PRINTED B NATURE) GATE <br /> LOCAL AGENCY USE ONLY <br /> CCOO�NTY�# JURISDICTION# AGENCY# FA #of TANKS at SITE <br /> 5- a <br /> CURRENT L GENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> D I a3 OC-UP3 a YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AM UNT FEE CODE RECEIPT# (D BY: <br /> NIIN <br /> oil <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)^"MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.�•/-�� <br /> A(11 -�) — 0� I DATA PROCESSING COPY J/� <br />