Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD '�P <br /> SITE v UNDERGROUND STORAGE TANK PROGRAM ;�a�n' Ngo <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION .. <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> r <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ONE ITEM ❑ 7 TLv CL SED SITE N <br /> 2 INTERIM PERMIT q AMENDED PERMIT <br /> E16 TEMPORARY SITE CLOSURE '' /) Im <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) v <br /> N <br /> FACILITY/SITE N <br /> CARE OF ADDRESS INFORMATION <br /> AM <br /> G — M A4 C. I lIVi 7Jj <br /> ADDRESS <br /> `8 —7 L N:— fl— /' 1. I NE ESTCRO SSTRE T ✓gpeb Mvl¢ ❑ PNITNER%W ❑ STATE AGENCY <br /> v I 1, I!�/ / ❑ caflPOIUTION O LOCAL CENCY ❑ FEOEnu AGENCY <br /> CITY NAME / IWWOM Q GAINTYAGENCI' <br /> STATE ZIP CLOD _ SITE PHONE N,WITH AREA CODE <br /> �7 1 <br /> TYPE OF BUSINESS: E]p DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA D If <br /> A 7 w 7$ <br /> 1 GAS STATION 0 3 FARM 5 OTHER RESERVATION orI ❑ M of TANK'Y TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST l <br /> PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CApE OF ADDRESS INFORMATION <br /> MAILING o,STREET ADDRESS <br /> I/BOA le RATIO'cale ❑ PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCALAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS <br /> INFORMATION <br /> MAILING or STREET ADDRESS I <br /> ✓Box to'w',, le 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> CITU NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> 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 BOTN LEGAL NOTIFICATION AND BILLING: 1. 11 IL ❑ 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('HINTED&SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY NJURISDICTION N <br /> E <br /> AGENCY# FACILITY IDN <br /> N of TANKS at SITE <br /> CURpENT LOCAL AOENCY FACILITY ID N <br /> 1 APPROVED BY NAME <br /> PHONE Y WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIpATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DIST T ODE <br /> 10' 2 '> 17 BUSINESS PLAN FILED <br /> /] DATE FI} D <br /> YE$ ❑ <br /> CHECK# PERMIT AMOUNT O� <br /> SURCHARGE AMOUNT FEE CODE <br /> RECEIPTY B <br /> Y. <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 /> FORMA FORM) <br /> DATA PROCESSING COPY <br />