Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> S� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> G COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> OR P <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT E 6 TEMPORARY SITE CLOSURE <br /> .7� <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Go ,N e <br /> ADDRESS NEARESTCROSSBTREET ❑ PARMOSIF ❑ EAoE;y N <br /> & �,� Cl <br /> C9'conPORArIau 11 �OCALAGB;Y 71FF»Enu1A64CY � <br /> INDIVIDUAL ❑ MUNO-AGENO( W <br /> CITU NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE (� <br /> CA <7o1 Oy <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 P OCESSOR ✓So.it INDIANESERVATION <br /> EPA IDa <br /> ❑ 1 GAS STATION ❑ 3 FARM 02"5OTHER TRUSTT LANDS� E__1nt Ir-0— AT THAS SITE lJ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE 9 WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION 8, ADDRESS - (MUST BE COMPLETED) <br /> NAME Poo l) ear , i re F 1?,wh bet- Co, CARE OF ADDRESS INFORMATION <br /> MAILINGIIorr STREET ADDRESS ✓X.to maicale ❑ PARTNERSHIP ClSTATE-AGENCY <br /> L44 E, u ��A CORPORATION ClLOCAL-AGENCY IJFEDERAL-AGENCY <br /> Cl INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME /STAAT{E/� ZIP ODE PHONE M.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME 2 fl r CARE OF ADDRESS INFORMATION <br /> Su 1 <br /> MAILING or STREET ADDRESS ✓Box to',ta. Ste ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CRY NAME STATE ZIP CODE PHONE 0 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. >4 it. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY IDN N of TANKS at SITE <br /> D 9 = ooa o 7 (0000 <br /> CURRENT LOCAL AGENCY FACILITY ID 0 APPROVED BY NAME PHONE a WITH AREA CODE <br /> moo D <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE I LENSU1B TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> D c c 3, 0-62' YES ❑ NO ❑ 8 a! el <br /> �\ CHECK a PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT a B <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-Wt, <br /> DATA PROCESSING COPY <br />