Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD �o <br /> 56P... <br /> 1 1 <br /> FORM A : UNDERGROUND STORAGE TANK PROGRAM �o <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'bJ_og9`i <br /> MARK ONLY F-11 NEWPERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION 7 PER C�O/$�E�DS E <br /> ONE ITEM 1:71Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE -� <br /> I® <br /> 60 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACIIITV/$ITE NAME CARE OF ADDRESS INFORMATION <br /> HIVE, -F r( ro <br /> ADDRESS I. fI NEAREST CROSS STREET ✓ilmit Gtab ❑ PAIUNENSHIP 0 STATE-AGENCY (� <br /> / L�/I C xp 0 ODFMMTKN 1:1LOCALAGENCY 0 FM4-AGENCY <br /> ' ` J r 1. ❑ INOMI ❑ O7UNT1'-AGING( <br /> CITY NAME STATE ZIPCODE SITE PHONE If,WITH AREA CODE <br /> S o5a <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box N INDIAN EPA ID a #of TANK'N <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTRYLANDS or ❑ AT THIS SITE <br /> 11 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,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 ✓Box to Indicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If,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. ❑ 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# JURISDICTION If AGENCY# FACILITY tD# #of TANKS at SITE <br /> m <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBED PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES � NO <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> HIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION <br /> PM A(8-2-881 /—� -... <br /> (w, DATA PROCESSING COPY <br /> r <br />