Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMA': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE T FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ` io <br /> I COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE _4 <br /> fJi <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) -4 <br /> Ln <br /> FACILITY/SITE NA L - CARE OF ADDRESS INFORMATION <br /> N!c r.l; PoNaid gus5ed <br /> ADDRESS NEAREST CROSS STREET ✓ bilhole ❑ PATINBiRIP ❑ STATEnGE1LY <br /> IXMPOUTION 0 LOCAL4 WO ❑ RDEIW-A DD <br /> S j gSlaW ❑ Co w/L ❑ ODURTYAGGILY <br /> CITY NAMES E ZIP CODE SITE PHONE#.WITH AREA CODE <br /> O).L CA 2 90 <br /> TYPE OF BUSINESS: 0 ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> RESERVATION or ,( '1 C A of TANK'I <br /> ❑ 1 GAS STATION ❑ 3FARM 50THER TRUSTLANDS ❑ N(�1/�lE AT THIS SITE 0 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> CA NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ell tat - 0s <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS' •NAMg(LAST.FIRST) PHONE a WITH AREA CODE <br /> II. PROP TY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAMEA_r CA DEAD <br /> 1DRESSIN RMATIOpN <br /> MAILING or STREET ADDRESSQrCox tb indicate ❑ PARTNERSHIP 11 STATE-AGENCY <br /> 0. pox ❑ CO <br /> NDRVIDUALION [I COUNTY-AGENCY AGENCY 11 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CI NAME STATE ZIPCODE PHONE N,WITH AREA CODE <br /> o e o 0,t 17535-2— Soo-g2 - <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> e as <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME 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: I. ❑ 11-dIII.❑ <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# JURISDICTION If AGENCY# FACILITY ID If N of TANKS H SITE <br /> CURRENT LOCAL AGENCY/FACILITY ID# APPROVED BY NAME PHONE a WITH AREA CODE <br /> 0/ <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIONCODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED OATl PILED <br /> Z 2 p!1 YES NO <br /> CHECK# PERMIT AMOUNT SURCMR09 AMOUNT FEECODE 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 ONLY. <br /> FORM A(3-2881 F�'�. <br /> Q4-- DATA PROCESSING COPY <br /> V <br />