Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> � a <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE /' FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> L COMPLETE THIS FORM FOR EACH FCILITY/SITE <br /> MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 7 <br /> ICD <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITEN E CARE OFA ESS INFORMATION <br /> c NEAREST OSS STR ✓B0,la Now, 0 PAITNEISHIP 0 STATEAGENCYN <br /> ADDRESS / C—r. awl ❑ INDNDUALTo' 0 13 LCDUNW.AGENCY ❑ FEDEPAL AGENCY co <br /> CITY NAM ST <br /> ZIP CODE SI�� NE��J AREAD� a) <br /> TYPE OF SINESS: ❑ 2 1STRIBUFOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID a J #oITANK's <br /> RESERVATION or <br /> [�Orl GASSTATION [—]3 FARM E] AT THIS SITE 5 OTHER TRUST LANDS ❑ <br /> 00— <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAY1, NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: AME(LAST,FIRST) PHO WITH AREA CODE <br /> NIGHTS: NAME(I-AST FIRST) + PHONE q WITH AREA CODE NIAME(LAST,FIRST) PCO k WITH AREA CODE <br /> ZOO -S'3/Jr VAN �6 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> I <br /> NAME CARE OF DDRESS INFORMATION <br /> MAKING or STREET ADDRESS" Bon to inCiwte 13 PARTNERSHIP 13STATE-AGENCY <br /> 0 9ORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL 0 COUNTY-AGENCY j <br /> CITY E STATE ZIP CODE PHONE WI HAREA CODE 1 <br /> S'2�v43 <br /> III. TANK OWNER I ORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE RESS INFORMATION <br /> MAILING ar§TREET DDRESS <br /> ✓Box to ind1cate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> O�00RPORATION 0LOCAL-AGENCY 0FEDERAL-AGENCY <br /> II INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATEZIP C PHONE#,WI AREA CODE <br /> 5 1A <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. ❑ 11. IIL ❑ <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 A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION At AGENCY# FACILITY ID# #of TANKS at SITE <br /> [� 00 ! 64� 10101610 <br /> CURRENT LOCAL AGENCY FACILITY 10# APPROVED BY NAME PHONE#WITH AREA CODE <br /> P RMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA ODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED AEFIL <br /> YES [_]ED <br /> NO A L <br /> CNECK# PERMIT AMOUNT SDRC GE AMOUNT FEE CODE RECEIPT# 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 INFORMATIONpNLY� <br /> FORMA)3-2-80) \\\� <br /> DATA PROCESSING COPY <br />