Laserfiche WebLink
STATE OF CALIFORNik- WATER RESOURCES CONTROL BOARD <br /> FORM W: `UNbkRGROUND STORAGE TANK PROGRAM <br /> SITE �� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° Z <br /> COMPLETE THIS FORM FOR EACH FA ITY/SITE `'�•�ee�" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE �¢ ) <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> n <br /> ADDRESS NEAREST CROSS STREET ✓ft l0iHnk D PARTNERSHIP D STATE'AGDCY <br /> D WIPGRATON 0 LOGLAGDO 0 RGERN'AMMY <br /> D II&INDIIAL D 0amn.A000 <br /> CITY NAME STATE ZIP CODE SITE PHONE V.WITH AREA CODE <br /> CA /-Ys/ ago <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR F-1 4 P R ✓BOx if INDIAN EPA ID A #of TANK'F <br /> ❑ I GASSTATION ❑3 FARM OTHEfl TRUSTYLANDS ION m ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(UST,FIRST) PHONE F WITH AREA CODE DAYS. NAME(I-AST,FIRST) PHONE A WITH AREA CODE <br /> r T4 »J J9 <br /> NIGHTS NAME(IASi.FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 54' Fr�Q <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Inolcete D PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CRY NAME STATE ZIP CODE PHONE M,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sul R 5 1 <br /> MAILING or STREET ADDRESS ✓SO.to Inolcete 0 PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> D INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATS 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: 1. 11. 111. ❑ <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 D JURISDICTION R AGENCY# FACILITY ID R #of TANKS BE SITE <br /> ED = = D / D d d © C-) / <br /> CURRENT LOCAL AGENCY FACILITY ID E APPROVED BY NAME PHONE S WITH AREA CODE <br /> �f7iv,vA cl <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIOqN CODE CEHM MACT0 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> a39D I 3YES ❑ NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTF BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST TR MORE TANK PERMIT FORM 'B'APPLICATION(S), U' S THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(&R&B) <br /> /'� T DATA PROCESSING COPY w <br />