Laserfiche WebLink
STATE OF CALIFORNIP - WATER RESOURCESCONTROt80ARD <br /> FORM 'A'pj a UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FJ►CILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT fn 5 CHANGE OF INFORMATION ❑ 7 LOSEO SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAM?�i_7� /� O MTS / CARE OF ADDRESS INFORMATION <br /> ADDRESS Z IK�/V"���� p [•//K/-G„N-r NEAREST CROSS STREET ✓Bm rovbrale ❑ PAWNOMIP ❑ STAIE AGRID <br /> 1 ✓ O &t44� ❑ INDGMWAALDN ❑ Ip NAA ❑ FEDERAL AGENIT <br /> GBicy <br /> CITY NAME STATEZIP C D SITE PHONE N,WITH AREA CODE <br /> S CA "ZOl <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR d P ESSOR ✓Rox if INDIAN EPA ID a <br /> RESERVATION or Mol TANK1 <br /> ❑ 1 GAS STATION ❑3FARM SOTHER TRUST LANDS ❑ I AT THIS SITE `L <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 4�v �N Q” Z41-17W4 �` L `fid —Z Op <br /> NIGHTS: NAME(LA.19T.FIRST) J PHONE#WITH AREA CODE NIGHTS: NAME(LA IRST) PHONE B WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME / �� ����/ CARE OFJI RESS INFORMATION���x�� M quR/.5( _ A <br /> MAILING or STREET ADDRESS ✓Box to indicate L/•/(❑l PARTNERSHIP ❑1 STATE-AGENCY <br /> "/ <br /> / L ClCORPORATION [3LOCAL-AGENCY ClFEDERAL-AGENCY <br /> 1677.57Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE ONE H,WITH AREA CODE <br /> SA-7vTos e, Gv&- ' Z / <br /> III. TANK OWNER INFORMATION <br /> ,.&ADDRESS - (MUST BE COMPLETED) <br /> NAME I-:-r r— % NSI CARE OF ADDRESS INFORMATION <br /> _ci_10- 4 1+ <br /> MAILING or STREET ADDRESS 13 O //� ox la intlicate 13 PARTNERSHIP ❑ STATE-AGENCY <br /> Q 1 („/ NDIVIDUAL'ORATION 11 LOCAL-AGENCY D 1:1 COUNTY AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE �/ PHONE M.WITH AREA CODE <br /> (�i• <br /> YC IA'" - S — 'l 6 —Z-J'd <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, it. ❑ III.ot <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 R JURISDICTION 11 AGENCY R FACILITY ID N N of TANKS at SITE <br /> 101 L9 713 � � ov <br /> CURRENT LOCAL AGENCY F LiY IO�� APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER 7 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACTM SUPERVISOR-DISTRICT CODE BUSINES YPLAN FILED NO ❑ DATE FILED <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT% 'BYYx: <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 INFORMATION/ONLY. <br /> FORM A(3-2-88) <br /> 11A.0 DATA PROCESSING COPY fPJ �_ <br />