Laserfiche WebLink
moo. <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SM FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 'S <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 <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE anL <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 1 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> I NIS <br /> ADDRESS S NEAREST CROSS STREET ✓&A to rAitale ❑ PARTNERSHIP ❑ STATEAGENCY <br /> /\' o <br /> El CORPORATION El LOCAL AGENCY ❑ FEDERAL AGENCY 00 <br /> 00 /I fie v/�v� (4m ❑ INDIVIDUAL ❑ COUNIKAGENCY '4 <br /> CITY NAME STATE ZIP GO E SITE PHONE W.WITH AREA CODE <br /> 451 O CA <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box d INDIAN EPA ID a <br /> 0.1 TANK's <br /> 1 GAS STATION 3 FARM 5 OTHER TRRUSTVATION LANDS o <br /> L] ❑ N/V AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAME(LAST,FIRST) PHONE 9 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 19 Av7U/V/fI 0-91f30 <br /> NIGHTS'. NAME(IASL FIRST) ^/ PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE K WITH AREA CODE <br /> I <br /> 11. PROPERTY OWN9R INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME at l V/ D�/v /v /+• CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS /� ✓B o indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> RPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> F� INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION/& ADDRESS — (MUST BE COMPLETED) <br /> 55 <br /> NAME b\ D {� � •') CARE OF ADDRESS INFORMATION <br /> MAILING o,STREET ADDRESS IV ✓B o indicate ❑ PARTNERSHIP Cl STATE AGENCY <br /> O/ A/p ❑ ORPORATION LOCAL-AGENCY El <br /> O <br /> J l� ✓ (fI INDIVIDUAL ❑ COUNN AGENCY <br /> CITYNAME STATE ZIP CODE �. PHONE N,WITH AREA CODE <br /> S7lE G>�} l > —Z6—W3 <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. ❑ it. ❑ 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 k JURISDICTION N AGENCY R FACILITY ID N k o/TANKS at SITE <br /> o1 o ,;�- 13 1oOz <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PSN FILED NO ❑ DATE FI}E' <br /> CHECK+ PERMIT AMOUNT SURCHARGE AMMOUNrNTT) FEE CODE RECEIPT It QD/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 13-2-88) Jl <br /> DATA PROCESSING COPY v <br />