Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTRO&106ARD <br /> C 9 <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 ENTLY CLOSED SITE y <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE G <br /> 1® <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SRE NA CARE OF ADDRESS INFORMATION <br /> e S 7/!J ro <br /> ADDRESS ^ NEAREST CROSS STREET xloinEKBle ❑ PARTNERSHIP ❑ STATEAGENCY <br /> COAP00.4ilON ❑ LOCA AGENCY ❑ FEGEML AGENCY Fj <br /> NOVIDUAL ❑ COUNTY-AGENCI <br /> CITY NAME STATE ZIP CODE SITE PHONE#. ITH AR70DE <br /> C S 6 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ ESSOR ✓Box ii INDIAN EPA ID # <br /> RESERVATION or #of TANK'S <br /> ❑ I GAS STATION ❑3PARM 50THER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST.FI ) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 1•f [ # <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> F � � <br /> MAILING or STREET ADESS INDIVIDUAL; <br /> z to Indicate ❑ PARTNERSHIP 11 STATE-AGENCY <br /> / AION Cl LOCAL-AGENCY 13 FEDERAL-AGENCY YET4 _ � NDIVIDUAL ❑ COUNYAGENCY <br /> CITY NAME `/ STATE ZIP CODE PHONE#,WITH AREA CODE <br /> /—O5 ATl Pi e! C14df12,1f--74T--5X00 <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME Lza CARE OFADDR SS INFORMATION <br /> MAILING or STREET ADD ESS ox to RATIIO El PARTNERSHIP ❑ STATE-AGENCY <br /> CJ( / CORPORATION 11LOCAL-AGENCY11FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP COD 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. ❑ if. ❑ 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# AGENCY# FACILITY ID# #of TANKS at SITE <br /> ® = (�; / C11 <br /> CURRENT LOCAL AGENCY FACILITY ID APPROVED BY NAME PHONE#WITH AREA CODE <br /> e 6 d �'� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIONC/BODE CENSUSTRACT# SUPERVI R-0ISTRICT CODE BUSINESS PLAN FILED DATE FILED 2 Q YES ❑ NO 1:14—I <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 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(3-2-98) `J/l <br /> r... DATA PROCESSING COPY •./ <br />