Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE ^ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> v COMPLETE THIS FORM FOR EAC FACILITY/SITE "'•�"='" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I.► <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 0 <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME_ �C'�S tU 64L& <br /> S �� CARE OF ADDRESS INFORMATION <br /> ADDRESS Ti(jJ NEAREST CROSS STREET bitlirale Cl PNRNRSHP D STATE AGBILT <br /> WWOPATION D LOCALAODCr D FENEIMLAGEO <br /> Al INpNWAL ❑ WIINTY-AGBICY <br /> CITY NAME STATE ZIP COD SITE PHONE N,WITH AREA CODE <br /> CA <br /> F-19520 <br /> TYPE OF BUSINESS. p DISTRIBUTOR /PROCESS011 VBOX if INDIAN SERVATION or EPA ID a Mal iANK'a <br /> ❑ 1 GASSTATION [—]3FARM ID5OTHER TRUST LANDS ❑ AT THIS SITE / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAjVE;(AST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME ST,FI T) PHONE N WITH AREA CODE NIGHTS: NAME(LAST, RST) f PHONE N WITH AREA CODE <br /> l <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME 0KX^ _O K5— i CARE OF ADDRESS INFORMATION <br /> MAILING or STREET AD s5ox to indicate D PARTNERSHIP D STATE-AGENCY <br /> CORPORATION Cl LOCAL-AGENCY D FEDERAL-AGENCY <br /> D D INDIVIDUAL D COUNTY-AGENCY <br /> CIT'NAME STATE ZIP C �5 _//W//^�( 1 PHONE A.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE/VCOMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS Bon to indicate D PARTNERSHIP D STATE-AGEN <br /> CORPORATION D LOCAL-AGENCY D FEeERAL-AGE CV <br /> D INDIVIDUAL 1:1 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOIL INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'$NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY11 JURISDICTION R AGENCY R FACILITY ID R R of TANKS RI SITE <br /> 0 1010d1 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED 8Y NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIONCODE CENSUS TRACT <br /> 2 (Jrj(�l SUPERVIY1STRICT CODE BUSINESS PI-All D ❑ DATE FILED <br /> resOZ a I - <br /> NO <br /> CHECK F PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N <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(3-288) V _ <br /> DATA PROCESSING COPY <br />