Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMW:: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> 'T COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> _L_ <br /> MARK ONLY ❑ I 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 a <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OFADDRESS INFORMATION <br /> R, Ic. DOIN( <br /> ADDRESS yn ,./I NEAREST CROSS STREET ✓Bmx,rxxsV ❑ PABTNMIP ❑ STATE A390 <br /> 2 N A1J 1� W/ 2 ❑ C FOMTON ❑ LOCAL AGENCY ❑ IMERALAS90 <br /> INOMOULL ❑ CW m-Aaac, <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> LI *N) CA <br /> TYPE OF BUSINESS2 DISTRIBUTOR 4 PROCESSOR //Box if INDIAN EPA ID N /r. N of TANK'Y <br /> RESERVATION1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUSTT ANDS ur ❑ uN^ AT THIS SITE I <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAMENAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> L>6'it.-;P- If7 .<O� &A,k <br /> NIGHTS' NAME(LAST,FIRST) HONE N IT <br /> WH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> oa2inAi U/vl< <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> vn 4S <br /> MAILING or STREET ADDRESS ✓Box toindlcate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME• 1 CARE OF ADDRESS INFORMATION <br /> ST <br /> MAILING or STREET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE DECODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WNICN ABOVE ADDRESS SHOULD BE USED FOR BOTN 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 N JURISDICTION M AGENCY N FACILITY ID R R of TANKS at SITE <br /> 0 10 1 I 15 Iq I I O I b e <br /> In I- <br /> CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE N WITN AREA CODE <br /> Q� r <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> xx <br /> LOCATIQON(F�ODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED .! <br /> 1 r� z �. YES ❑ NO O ( SS C-4 <br /> CNECK N 1 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 INFORMATI0�'bNLY. <br /> FORM A(3-2-113) <br /> V �/ <br />