Laserfiche WebLink
STATE OF CALIFORNh[ WATER RESOURCES CONTRbeBOARD `� �• "e <br /> 1 , <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ,o <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY LOSEO SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 3 - <br /> cn <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SIT NAME CARE OF ADDRESS INFORMATION <br /> ,NN -� <br /> ADDRESS - NEAREST CROSS STREET 5s ✓BM mhtirale ❑ PARTNUMIP ❑ STATE AGENCY N• �^ R 0 COWOMTIOY 0 LOCM AGEHCY 0 iEOEMLAGENCY <br /> O INDMDML ❑ COUNlY MINa <br /> CITY NAME STATE21yC�UF� / SITE PHONE It,WITH AREA CODE <br /> CA 7J ,!/!Y/L' <br /> TYPE OF BUSINES : ❑ STRIBUTOR ❑ 4 PROCESSOR ✓Box rf INTION or #of TANK s <br /> DIAN EPA ID n <br /> - <br /> E:] I GAS STATION RESERVA3 FARM ❑5 OTHER TRUST LANDS El THIS SITE 000/ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS. NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(I-AST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAMECt5 CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE#,WITH AREA CODE li <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME a ! CARE OF ADDRESS INFORMATION III <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE#.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. 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'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID If If of TANKS at SITE <br /> ® � I I I Z/ � 101210111 <br /> CURRENT LAC/IIiAGfN`JJ} II„[`CY FA�ILIT 10# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER (J-\J U PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS YPLAN❑FILED NO ❑ DATE FI/D <br /> CHE K# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 6 B : <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(3-2-88) <br /> ayy! DATA PROCESSING COPY \/ <br />