Laserfiche WebLink
STATE OF CALIFORNI ke, WATER RESOURCES CONTROL-dOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> S� M FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK GNLY 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE9T F <br /> N <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) CY) <br /> FACILITY/SITE NAME <br /> CARE OF ADDRESS INFORMATION <br /> ADDRESS }� NEAREST CROSS STREET ✓ to ir-To ❑ PAfliNEF�RIIP ❑ STATE RGENCY <br /> {..�• '{�„(_',(�Ii,4/,'u-,i�Q• COflPOPAiION ❑ <br /> LOCAL AGENCY ❑ FFDPA AGENCY <br /> ❑ INDMWAL ❑ COUNTY AGENCY <br /> CITY NA STATE ZIP CODESITE PHONE N.WITH AREA CODE <br /> CA <br /> (av 3Co7(o <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box/INDIAN EPA ID N <br /> RESERVATION or /1 /{� X of TANICS <br /> ❑ 1 GASSTATION ❑ 3 FARM OTHER TRUST LANDS ❑ ///E/ YLJ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> o Cao9 0 4e <br /> NIGHTS: N M (LAST,FIRST) PHONE M WITH ARA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY, <br /> CITY NAME STATE ZIP CODE PHONE M,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> G <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE M,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ IN.❑ <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 S SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY K JURISDICTION N AGENCY M FACILITY ID N R of TANKS at SITE <br /> IM = = 101o 1 7 10 1 00 <br /> CURRENT LOCAL AGENCY FACILITY IDN APPR VE BY ME PHONE M WITH AREA CODE <br /> SID L" <br /> PERMIT NUMBER PERMIT APPROY DATE PERMIT EXPIRATION DATE <br /> ba 111 -1 !Vllklail <br /> LOCATON CODE CENSUS TRAC N SU RVISOR-DISTRICT CODE BUSINESS N FIL D DATE FILED <br /> D a 1 � YES ❑ NO <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT <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 /> FORM A(3-2-88) _ <br /> Lr, DATA PROCESSING COPY <br />