Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> •a <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM V <br /> _� <br /> SITE- FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> ECOMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENT Y CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Moo <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILI7YBITE NAME i / CARE OF ADDRESS INFORMATION <br /> 7��f` <br /> ADDRESS �� n /� / NEAREST CROSS STREET <br /> 11 PAHMBSHIP ❑ SRAiE1GEMY <br /> ( le? Cl FEDERAL ArDO❑ MWr ❑ u , a <br /> 0 DNOW D ODUNTAGENV <br /> CITY NAME /"� ^ �/ { - STATE ZIP CODE�® SITE PHONE N,WITH AREA CODE <br /> TYPE OF BUSINESS ❑2 !Po c&NYLOfl'VArn❑`/PROCESSOfl ✓Box A INDIAN EPA IO p E of TANKY / <br /> RESERVATION or ❑ AT THIS SITE <br /> ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE Al WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> i oZQ Y <br /> NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> ao 5L 7 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME S/ <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or ST EET ADDRESS T ✓Box to indicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> D CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> D INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME ^ /A J� CARE OF ADDRESS INFORMATION <br /> MAILING or STREe ADDRESS T ✓Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONEN,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR MOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 111.❑ <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 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY K JURISDICTION S AGENCY B FACILITY ID R M of TANKS at SITE <br /> DO 1 S / 05 10001 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> I- EDoR l <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCAT NCODE CENSUS TRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN❑FILED DATE FILED <br /> YES NO ❑ <br /> I OL <br /> CNECKN PERMIT AMOUNT SURC GEASIOUNT FEE CODE RECEIPTa B . <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 /> l FORM A(3-2-88) <br /> IV,`�, <br /> 9-19-�q. -- <br />