Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
- - --- .•^•��, .,�.Avunt,caL.vrvLnu� tiOARD <br /> 0RM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION :.. <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ,b <br /> MARK ONLY ❑ 1 NEW PERMIT E] A <br /> 7 RENEW . RMIf <br /> ONE ITEM ❑5 CHANGE OF INFORMATIONJ <br /> ❑21NTERIM PERMIT ❑ 4 AMENDED PERMIT <br /> ❑6 TEl -eW0WqYfIOSED SITE. <br /> TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION S ADDRESS — (MUST BE COMPLETED) <br /> MT AME <br /> OF AOOIESS miONMATION <br /> SS (� <br /> REsI CROSS STREET ttl,wlIXy ❑ ftmxR ❑ STAR <br /> CAW .IGS'GY <br /> (V ❑ mvamrol ❑ Lanc+awr ,YA. <br /> NAME ' <br /> ❑ FODM <br /> 1 STATE Z1 ❑ COIFIM1JfOK'Y <br /> �Z AHONE t,VRTN AREA CODE ,j>, <br /> CA <br /> (/�)�p�eBVS <br /> Of NESS' ❑204I�/TOR ❑IRIOCESmR ✓BatMDIAN EPA R)0 <br /> r <br /> T�l 1 GAS SIMON ❑ 7 FARM ❑5 OTHER RESERVATIONTRUST ON a' ❑ I j 1 of TANK's �y <br /> EMERGENCY CONTACT PERSON(PRIMARY) AT THIS SITE <br /> EMERGENCY CONTACT PERSON(SECONDARY) <br /> NAME(LAST,FIRST) <br /> PHONE•,PIM AREA CODE DAy� NAAE AAST,i111$T) <br /> S /�'1 PHONE.WITH AREA CODE <br /> HrILITS: NAME(LAST.FIRST( (� <br /> S <br /> PHONE•W TN AREA CODENIGMM <br /> CNAAE(LAST,FIRST) PHONE t WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION 6 ADDRESS—(MUST BE COMPLETED) I' <br /> 1 <br /> CABC1F ADDRESS INFORMATION <br /> IX STREET ADDRESS ( J�+✓Jgyb� ❑ PARTNERSHIP <br /> COIPoRATK (A <br /> M ❑ LOL ❑ STATE-AGENCY •I <br /> AME ❑ MOMWAL 11 AGENCY <br /> COUNTY- ❑ FEDERAL-AGENCY `1 <br /> /4 S bP CODE PH ,WITH AREA CGOE <br /> 2/ .2f/ <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> �> ADOIRESS W*ORMATIDN <br /> a STREET AOO{ESS <br /> ✓SIX 1P ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ COR OPATION O LOCK-ADEN(-Y ❑URAL.AG <br /> CITY NAME O INDWIDUAL ❑ COWRY-AGENCY ENCf <br /> Z�J STAT ZIP PN MTH AREA CODE <br /> IV._IEGAL NOTIFICATION AND BILLING ADDRESS <br /> EH^ONE(1)BOA INDICATING WNICN AIOr[ADDR[u SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BKUN2 t ❑ It. ❑ <br /> ut❑ <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 6 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> OUHTY a T JURISDICTION 4 AGENCY <br /> �u II'I�' I�I�II' III J FACILITY ID F --L' . '; fi G of TANKS N SITE <br /> JA <br /> LOCAL 40INHCY FACN.RT 10 t <br /> CON NAMIE, <br /> P""0 WITH ARU COD[ <br /> MRNUMBER / A ROVALDATE Cr C <br /> 'T/1T10N--DAT[ <br /> COD[ N .TRACT• � YItOR-0ItTIHKT COOe <br /> RA,1 rlLlO F1Le0 <br /> YE9 p NG E03 <br /> CHECK, RMrt AMou1rt cNAAoe AMo1NiY Fee coos <br /> ■ecel.YF my: <br /> 7GRM MUST/E ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMEE FO R M 'B'A➢PUCA <br /> TION(S),UNLESS THIS ISA CHAIIGE OF SITE INFORMATION ONLY. <br /> -ACJ ._ ,e.r• ..,. .� <br />