Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM NA': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ N AMENDED PERMIT -❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> G <br /> ADDRESS // //�� 11 NEAREST CROSS STREET ✓BN . D PATTND61W D STATE AGENCY <br /> �3E�7S W• D U*0RkTNN D LOCH AGENCY D HOEAk AGOCY <br /> ❑ NwoI D CDNIY-AGENCY <br /> CITY NAME - STATE 21P CODE SITE PHONE A.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS' ❑ 2 DISTRIBUTOR ❑ /PROCESSOR ✓Box it INDIAN EPA ID A 1 of <br /> ❑ ❑ ❑ <br /> RESERVATION IY ❑ AT THISI SITE I GASSTATION 7 FARM 5 OTHER TRUST LANDS AT THIS 617E <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE A WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTSNAME(UST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boa to itWlcale D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL AGENCY <br /> Cl INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE 21P CODE PHONE A,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING n STREET ADDRESS ✓so.Io II "'o D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL AGENCY ❑ FEDERAL AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE 21P CODE PHONE N,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. ❑ II. ❑ 111.❑ <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 E AGENCY11 FACILITY 10 B B of TANKS B1 SITE <br /> = = = 237 El I 1 161 <br /> CURRENT LOCK AGENCY FACILITY ID N APPROVED BY NAME PHONE If WITH AREA CODE <br /> vsS�% 2 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E1IPIRATION DATE <br /> LOCATON CODE CEN/US TRACT N SUPERVISOII-0I11TRICT CODE BUBINEBB PLAN FILED DA D <br /> .2� YES E] NO d <br /> CHECK I PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST HI OR MORE TANK PERMIT FORM 'B'APPLICATION(S), U" -SS THIS IS A CHANGE OF SITE INFORMATIO40MLY. <br /> F FORM A(3-2-80) ws <br /> `j � <br />