Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM FA': UNDERGROUND STORAGE TANK PROGRAM \o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> I COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ ' MEWPERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Fj___�INTERIM PERMIT ❑ 4 AMENDEDPERMIT f�FI5 TEMPORARY SITE CLOSURE Zr <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 1 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> +1 e p - M ✓eea <br /> ADDRESS NEAREST CROSS STQ4T ✓fk+ a ❑ PARTNERSHIP ❑ STATE-AGENCY N <br /> ..11 RPOIATION 11LOCAL AGENCY ❑ FEDERAL AGENCY <br /> 1:7 e5�5 cavro"ax 14,u ❑ INDIVIDUAL ❑ COUNTY AGENCY w <br /> CITY NAMESTATCA ZIPCODE <br /> SITE PHONE#.WITH AREA CODE 1I <br /> 3 "'(^J,j`-(_) <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR [:] 4 PROC R I/BOA if INDIAN EPA ID N �^1 <br /> If of TANK's <br /> ❑ IGASSTATION 3FARM THER RESERVATION or . 10 THIS SITE o� <br /> ❑ TRUST LANDS ❑ 'V AT <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 /> a i a zol� Ci l&,n pug X39-dDO <br /> NIGHTS�- NAME( AST.FIRST) PHONE N WITH AREA CODE NIGHTS: NA LAST. PST) HONE k WITH AREA CODE <br /> l V 1 n ler 101 4 <br /> II. PROPERT WNE INFOR ATION &ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> ISP e Co <br /> MAILING or STREET ADDRESS ✓B intlinale ❑ PARTNERSHIP EDSTATE-AGENCY <br /> / ORPORATIIN ElLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> )I U U VQ- ch 1/e, ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 1/ V( I I� a rILTYI <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> PmtuQ Q �'LI o. RA J2, <br /> MAILING o,STREETADDRESS ✓Boxlo Ildl,, R 11 PARTNERSHIP ❑ STATEAGENCYf..) ClQ�C6RPORATION 11LOCAL-AGENCY ElFEDERAL-AGENCY <br /> 1 A 0 1 Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0,WITH AREA CODE <br /> t-AG/A P Cfn S <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. ❑ II. ❑ 111.ir <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) pgTE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION N AGENCY R FACILITY ID N N of TANKS BI SITE <br /> D 10 1I U 0 101 0 <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY ME PHONE M WITH AREA CODE <br /> avu <br /> PERMIT NUMBER PERMIT APPjtOV#i DATE PERMIT E IR ION DATE <br /> LOCATION CODE CENSUS TRACT N UPERVISOR-D TRICT CODE BUSINESS PUN FILED DATE FILED <br /> 2 a I VES ❑ NO ❑ -Z2- <br /> CHECK# PER <br /> AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> \N`Jr\\II HIS 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) - q <br /> \ `� DATA PROCE?S!NG COPY •-/ / <br />