Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> zCOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION E] 7 PERMANENT CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0 <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) w <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓&p b' ❑ PAATNERSNIP ❑ STAIEAGBtGY <br /> 7 p\TIDN D LOGAL-AGM D FE➢IX44AGDO <br /> D INDMDUN D ODUNTY-AGFNGY <br /> CITY NAME STATCA ZISI PHG NE p,WITH AREACODE <br /> ��� <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PM ✓Box if INDIAN EPA ID aN M TANSY <br /> , <br /> RESERVATION or <br /> E:] 1 GAS STATION ❑ 3FARM TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS VME(LAST.FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> 11Z nCS Z24f&& (.299_?ef 332E <br /> NIGHTS: NAME(LAST,FIRSTJ PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I/Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OFADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY 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. II. ❑ 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 /> COUNTY41, JURISDICTION M AGENCY# FACILITY ID If p of TANKS at S1TE <br /> G 13 13 (0 1I <br /> CURRENT LOCAL AGENCY FACIL1TYAD M APPROVED BY NAME PHONE a WITH AREA CODE <br /> so At-111 <br /> PERMIT R -- PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSIUSTRAC� SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> VES NO <br /> CHECSp PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTp Y: <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 /> RM A(3-2-88), <br /> �. DATA PROCESSING COPY —.� <br />