Laserfiche WebLink
STATE OF CALIFORfQ WATER RESOURCES CONTL BOARD <br /> " I <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o I o <br /> , COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY E:],)/NEW PERMIT ❑3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION 7 NENTLY CLOSED SITE <br /> ONE ITEM Ev 2 INTERIM PERMIT ❑0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURElb N <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE* _ L�/y�� CARE OF ADDRESS INFORMATION <br /> W N �I Ol a/7LOL I"J K/ S <br /> ADDRESS •y// 1/ /`y1 n �J 111I NEAREST <br /> �CROSS STREET brhak 0 PAAINERSHP 0 SIAIE-AGENCY <br /> / b 1 f AIk C F K/ T. C&V— ❑ INCGMDIAiION DJAL ❑ COUN1 AGENCY ❑ iFDERAl-AGENCY <br /> CITY NAME STATE / ZIP CODE SITE PHONE N.WITH AREA CODE <br /> S716 ` CA 2 m , q 8 7,-<1j13 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR 2d P EWR ✓BO%R INDIAN EPA ID * <br /> r RESERVATION or ,/7/E�, N of TANK'* �( <br /> ❑ 1 GAS STATION ❑3 FARM OTHER TRUST LANDS ❑ 'NJ <br /> AT THIS SITE (/ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(�T,FIRST) O PHONE It WITH AREA COPE DAYS: NAME(LASTST) PHONE p WITH AREA CODE <br /> K 98^l/7�0� al.�uL.e/ <br /> NIGHTS: NAME(LAST,FIR PHONE k WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME aA) sO Cl d4 /1 r_"I-, W f CARE OF ADDRESS INFORMATION <br /> MAILING or STREETtADDRESS (Jp)el�d ��+ ox to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 1 `/l CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE 0�� PHONE M, <br />