Laserfiche WebLink
STATE OF CALIFORNIX WATER RESOURCES CONTROL BOARD eSYS I <br /> FORM 'A': <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 ❑ / NEW PERMIT ❑ 3 RENEWAL PERMIT 155 CHANGE OF INFORMATION ❑ 7 PERMANENT LOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION <br /> ADDRESS U/� NEAREST O STREET ✓Bw0,,y� ❑ PMTNBOP 0 StATE-AGRO <br /> / �{ / OO cDWUAPPON 0 OMM <br /> MAGEN ❑ iFORUL AGEMt' <br /> r �FNDNIg1Al ❑ �UIPY#GRIL/ <br /> CITY NAME " STATE ZIP CODE ITE PHONE•,WITH AREA CODE <br /> �YXI CA to�' <br /> TYPE OF BUSINESS'. ❑ 2 DI BUTOR d PROCESSOR ✓Box if INDIAN EPA ID p <br /> RESERVATION or ❑ 1101 TAMC• O <br /> ❑ I GAB STATION FARM ❑ OTHER TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAY N ME(LAST,FIRST) PHONE•WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> Cao 3&8- <br /> NIGHTS' NAME 6 <br /> ST,FIRST) I PHONE•WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREe ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE•,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME S/ CARE OF ADDRESS INFORMATION <br /> S /4' e <br /> MAILING or STREItr ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP 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: 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 R JURISDICTION R AGENCY R FACILI Bi •of TANKS at SITE <br /> M = = O i l plololl <br /> CURRENT LOCAL AGENCY FACILITY ID• APPROVED BY NAME PHONE•WITH AREA CODE <br /> )rA <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L ON ODE CENSUS TRAC1T• SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> A . O� YES ❑ NO 02 a Q <br /> CHE • PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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(3-2-88) <br /> `,S -c� v <br />