Laserfiche WebLink
STATE OF CALIFORNI/X WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM :"� <br /> SITE % FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 10 <br /> MARK ONLY ❑ I NEW PERMIT D 3 RENEWAL PERMIT L] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE IJ <br /> ONE ITEM Z INTERIM PERMIT 0 4 AMENDED PERMIT [—]6 TEMPORARY SITE CLOSURE I <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) CA <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Can <br /> StAers <br /> ADDRESS (( �� � � ��/ NEAREST CROSS STREET ✓pm WIAio# 0 PARTNOIS,P 0 STATE AGM, <br /> p-Cw"e /Y%( ❑ WIPORANH+ ❑ LOCkVFNtx ❑ RWRuncB <br /> 13INUMDUAL ❑ coulm.AGIND <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> �e ^/ CA 5206 <br /> TYPE OF BUSINESS: 0 2 DISTRIBUTOR 4 PROCESSOR I/Box it INDIAN EPA ID x <br /> SEVATION1 GAS STATION W3 FARM 5 OTHER TRUST LANDS or ❑ - ##f TANK'# <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(I-AST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#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 <br /> Q L <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE*.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> YS <br /> MAILING or STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,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. ❑ IL ❑ 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# JURISDICTION M AGENCY# FACILITY ID If #of TANKS at SITE <br /> 3R 2 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE <br /> �O 4l6 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATI CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 92 , 2-X YES NO .< <br /> CHECK# tPIERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY: <br /> C=V I <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) ,�"� J <br /> �/ o-` � i�0 DATA PROCESSING COPY `aw <br /> �\Q <br />