Laserfiche WebLink
STATE OF CALIFORNbir WATER RESOURCES CONTROL'WARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> S!TFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FA ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E915'CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAMECARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STE ✓Ba bibrLe 11POTW W El STATE AGR0 <br /> //�� Jy�.. ❑ COTM TM 11LOCALAGENLY ElFEOEIAAL-AfENLY <br /> I L T I ❑ INOMMAL ❑ O MTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DI BUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA 10 N <br /> ❑ ❑ TRUSTYATION LANDS a ❑ `� " „-^�' AT THIS SITE <br /> I GAS STATION FARM 5 OTHER <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(UST,FIRST) PHONE p WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> ao 931- �a <br /> NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST( PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME [(pCARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS / ✓Box to indicate 0 PARTNERSHIP El STATE-AGENCY <br /> ,q (�, n <br /> El CORPORATION 11LOCAL-AGENCY0 FEDERAL-AGENCY <br /> i L, !.0%Y ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY AME _ .I STATE ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING wSTREEi ADDRESS ✓Box toinaicate 11PARTNERSHIP ElSTATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME TATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVB ADDI EBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ If. ❑ 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 N JURISDICTION R AGENCY M FACIL k of TANKS at SITE <br /> D 1 on I _tl D © o o <br /> CURRENT AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> L ' <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N BUPERVISOR-OIST111CT CODE BUSINESS PLAN FILED DATE FILE <br /> YES NO D <br /> CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(11 OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A 13-2-t)0), <br />