Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE Y $ aww�>_ t 0 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT0, <br /> ❑ 6 TEMPORARY SITE CLOSURES U Q. <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) uT <br /> FACILITY/SITE NAM co <br /> CARE OF ADDRESS INFORMATION <br /> ADDRESS NEARESTCROSS STREET ✓ <br /> COWMTO 0 PANTNEGEIP 0 SIN AGENCY <br /> CITY NAME <br /> — ( 5�- INDlcuraorulafl O0 aw�-A NCY ❑ r[oerul�u+cr <br /> STATE 21P CODE SITE PHONE I,WITH AREA CODE <br /> CA } <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box i11NDIAN EPA ID N <br /> ❑ I GAS STATION ❑ 3 FARM ❑5 OTHER RESERof TANK's <br /> TRUSTYLANDS or ❑ AT THIS SITE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION 1I <br /> MAILING or STREET ADDRESS ✓Box to,ftcale 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE 21P CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Sox to inoicwe <br /> (71 PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCYCITU NAME STATE ZIP CODE PHONE p,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 S JURISDICTION M AGENCY# FACILITY ID A S of TANKS at SITE <br /> I I I I I 3 �-1 <br /> CURRENT LOCAL AGENCY FACILITY 10• APPROVED BY NAME PHONE X WITH AREA CODE <br /> IQ, o S <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT• SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> NO <br /> CHECK X� <br /> YES PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE ❑RECEIPIT 0 ❑ BY /��✓ <br /> r <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 /> FORMA(3-2-88) <br /> �J .� DATA PROCESSING COPY �i / <br />