Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A : UNDERGROUND STORAGE TANK PROGRAM "m <br /> . <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; � 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE w <br /> ONE ITEM E] 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �v r <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Mata a Olds Buick <br /> ADDRESS NEAREST CROSS STREET ✓Sovmxdxale ❑ PANR4ARIN ❑ STATE-AGENCi <br /> ® CDRPMTON ❑ LOCAL AGENCY ❑ FEDEPX AGDCr <br /> 880 S o . Beckman Rd Vine ❑ INDIVIDUAL ❑ ODUNTV.AGExw <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> Lodi CA 95240 209-333-22j3 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID# If of TANK't <br /> RESERVTION5 OTHER A <br /> TRUSTLANDSNDS CAC 000573616 AT THIS SITE 1 <br /> I GAS STATION � ® TRUST <br /> 3 FARM <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(UST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Richardson Roger 209-333-2233 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Woods Bob 209-368-5425 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> O . I . Case Corp . <br /> MAILING or STREET ADDRESS BOX to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Q LOCAL-AGENCY <br /> 700 State Street ❑ INDIIVIDUALION ❑ COUNTY AGENC 11 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If,WITH AREA CODE <br /> Racine WI 1 53404 414-636-6011 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> J . I . Case Corp <br /> MAILING or STREET ADDRESS � 11 LOCAL-AGENCY <br /> Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 700 State Street ❑ NDIIVIDUALION ❑ COUNTY AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE J!,WITH AREA CODE <br /> Racine WI 53404 414-636-6011 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WNICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. E—] II. [j] 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&SIGNATUR DATE/�// <br /> W .T . Becker rg� <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# If of TANKS M SITE <br /> / 1713 151 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE M WITH AREA CODE <br /> C' sFP�s <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> PCHE <br /> ODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED23.$d 320 YES � NO � �?3 9/ <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: <br /> � <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST 111 OR MORETANKPERMIT FORM 'B'APPLICATION(S), UNLFSSTHIS IS A CHANGE OFSITE INFORMATION ONLY.pq <br /> ((L\L <br /> ORM A(3-2-88) \Ty <br /> DATA PROCESSING COPY <br />