Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A'; <br /> UNDERGROUND STORAGE TANK PROGRAM ;mom' <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑p INTERIM IMP <br /> AMENDED PERMIT <br /> ❑ ❑6 TEMPORARY SITE CLOSURE79 ­1 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) co11 <br /> FACILITY/SITE NAME ' CARE OF ADDRESS INFORMATION <br /> Af✓(A ac nN - dov <br /> ADDRESS <br /> NEAREST CROSS STREET ✓ birdKab ❑ PAPMERSIIP ❑ STATE ABENC( <br /> 3 � ❑ NOM�OM`IQY O LOCAL O ❑ FE)RAL-AGENCY <br /> CITY NAME <br /> hI•�eN STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> I� CA <br /> 5?36 2�-8� -391, <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR L'J 4 PgOCESSOfl ✓Box if INDIAN EPA ID a <br /> ❑ i GAS STATION ❑3 FARM 5 OTHER RESERVATION or N 01 TANK'i <br /> TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME LAST,FIRST) PHONE N WITH gREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 31r_ u14,✓ <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> �u�ir ass T <br /> MAILING or STREET ADDRESS %/Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 11 INDIVIDUAL ClCOUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> Ve <br /> MAILING or STREET ADDRESS ✓Box tc Ind,cate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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. ❑ 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 N AGENCY N FACILITY ID N N of TANKS at SITE <br /> ® � 16 10 / 5 6 10 10 to <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> RhAicl$O <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> C" YES [j NO 6 <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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(3-2-86) <br /> `i DATA PROCESSING COPY ai <br />