Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM ="° Z <br /> SITE n FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> l COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 195 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE IJ <br /> 22 -ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) CTI <br /> FACILITY/SITE NAM L CARE FADORESS INFORMATION I W <br /> fNEAREST <br /> , <br /> ADDRESS U <br /> ✓a"A'Awdo, ❑ PAAiNERS1IP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDEMLAGDIGY <br /> ❑ INOMDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE SITE PHONE pWITH AREA CODE <br /> CA <br /> TYPEOFBUSINEtS ❑2 DISTRIBUTOR ❑4 P SSDR ✓Bax if INDIAN EPA ID 4 <br /> ❑ i GAS STATION ❑ 3 FARM THER TRUST LANDS or ❑ F of TANKS <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS'. NAME( ST.FIRST) PHONE p WITH AREA CODE <br /> Li Ldq 6�-vy/s-' <br /> IGHTS: NAME(LAST,FIRST) � ,,,(, PHONE N WITH AREA CODE NI HTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> G✓ dj( / 23- <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS�INf/ORMATION , <br /> ;,E <br /> MAILING or STR ADDRESS ✓Box to indicr le ❑ EYRCI <br /> STATEAGENCY <br /> ❑ CORPORATION LOCAL-AGENCY FEDERALAGENCY <br /> AD Q ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> v rGy 523 <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE Ji,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. ❑ 11. III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANAME RINTED],SIGNATURE) re� DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY W JURISDICTION B AGENCY K FACILITY IDM R of TANKS at SITE <br /> i,�_ Jqj �: y <br /> CURB AL AGENCY FACILITY ID N APPROVED BY NAME PHONE X WITH AREA CODE <br /> PERMI ERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL D <br /> YES NO <br /> CH K♦ PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: LL <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 ON <br /> ORM A(3-2-N) <br /> DATA PROCESSING COPY �� <br />