Laserfiche WebLink
STATE OF CALIFORNIA' WATER RESOURCES CONTRO`eBOARD s•'•""^ l <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ""�^"•" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE IJ <br /> ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 6 r —4 Lrl <br /> I. FACILITY/SITE INFORMATION &ADDRESS —„(MUST BE COMPLETED) ul <br /> C.TI <br /> FACILITY/SITE NAME ^�I CARE OF ADDRESS INFORMATION <br /> PLCf-r& <br /> ADDRESSNEAREST CROSS STREET ✓BP.biUole D PARINB9MP D STATE AGENCY <br /> 15 bah 0 ( D GORPO FON INAMDUAL0 L .AGUICY D FMMAGPIY <br /> CITY NAME I AM'QN STATE 2952 SITE PHONE N,WITH AREA CODE <br /> IP CODE <br /> CAI <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ d PROCESSOR I '/Box H INDIAN EPA ID N <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSRESET LANDS VATION or ❑ AT TANK'# <br /> 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) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> Z' GS <br /> MAIL08iOr STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION Cl LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATEAGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTYAGENCY <br /> CITY NAOE STATE ZIP CODE PHONE#.WITH AREA CODE <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: 1. ❑ 11. ❑ 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(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> C�OU�N,TY/R JURISDICTION K AGENCY N FACILITY 10# N o1 TANKS H SITE <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE M WITH AREA CODE <br /> �S NI <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Z YES � NO 19 G—� <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <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 ONL� <br /> FORM A(3-2-BB) ,'M1(\\ <br /> ^� V O <br /> DATA PROCESSING COPY <br /> G' C ,, <br />