Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> G IO <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE t�I <br /> FMARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION IX 7 PERMANENTLY CLOSED SITE IJ <br /> ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE N <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 1 <br /> ADDRESS NEAREST CROSS STREET ✓Bmmintic&e ❑ PARTNERSHIF ❑ 9ATE.AGENLY <br /> 1 NE �� ❑�j�(y47�0.p'�W'RAnoN ❑ LOCA-AGENCY ❑ FEOEPWACENCY <br /> Il!INUIVIWAI ❑ COUNTY-AGENCY <br /> CITY NAME <br /> STATE ZIP CODE ITE PHONE N.WITH AREA CODE <br /> ( CA 953�(a $3 3b <br /> TYPE OF BUSINESS ❑ p DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> F-1I GAS STATION F-13 FARM �S�ER TRUSTYLANDS ATIONor 1:1 AT <br /> AT THHISIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) r PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> A.T=Souse 20 <br /> =] $35 3a �GNL u 35�33�c <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHT$'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Y^ T ❑ G(1�iPORATION 11LOCAL-AGENCY 11FEDERAL-AGENCYL 1 LINDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> C/h- ���635-`633p <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> M <br /> MAILING or STREET ADDRESS ✓Box to Irld,cate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> El 11 LOCAL-AGENCY 11FEDERAL-AGENCY <br /> d- IVIDUAL ❑ 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. ❑ if. If. ❑ <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> IIS CCOOU IN�T✓Y^R I� JURISDICTION K AGENCY k FACILITY ID K N of TANKS at SITE <br /> I = ' O O 101 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE k WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT K SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO ❑ <br /> CHECKk PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM BY: <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 /> DATA PROCESSING COPY <br />