Laserfiche WebLink
STATE OF CALIFORNIA' WATER RESOURCES CONTRdrtOARD ' <br />FORM'A': UNDERGROUND STORAGE TANK PROGRAM <br />SITE \FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION, <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br />ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 9-3 <br />I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />FACILITY/SITE NAME <br />CARE OF ADDRESS INFORMATION <br />CARE OF ADDRESS INFORMATION <br />MAILING or ST EET ADDRESS <br />/ x Ib <br />tt <br />,P. SO tiC" <br />S-�p VL CIA D <br />STATE <br />ADDRESS <br />Rx64 <br />NEARESTCROSS STREET <br />✓&abiHb 0 uPA1RTNR6NW 0 FAIE400 <br />LOCAL-AGENCY❑ FEOEWIAGENLY <br />//�/ <br />TN NNQN <br />rl l/ i <br />❑ INilON ❑ <br />CXINIY AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE p, WITH AREA CODE (l0 <br />i each <br />SURCHARGE AMOUNT <br />CA <br />5 : O <br />a <br />TYPE OF BUSINESS-. 712 DISTRIBUTOR <br />❑ a PROCESSOR <br />I/Box it INDIAN <br />EPA ID N <br />11 M TANK`a <br />❑ I GAS STATION �3 FARM <br />1:15 OTHER <br />TTRUSTYLANDS ATION or ❑ <br />AT THIS SITE <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYS. NAME (I -AST, FIRST) <br />PHONE N WITH AREA CODE <br />DAYS'. NAME (LAST, FIRST) <br />PHONE N WITH AREA CODE <br />F mle ae %b <br />C%4- -29.2"'? <br />-� <br />N/IG�HTS'. NAME (LAST, FIRST) <br />PHONE A WITH AREA CODE <br />NIGHIj AME (LAST, FIRST) <br />PHONE N WITH AREA CODE <br />571iiii <br />z29 -5W— ;29, <br />II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />NAME - _ <br />/ tiA%l C//iact�l/o�D /ina/ �ti5 <br />CARE OF ADDRESS INFORMATION <br />✓ Box to ind tate 0 PARTNERSHIP 0 STATE -AGENCY <br />0CORPORATION 0 LOCAL -AGENCY 0 FEDERAL -AGENCY <br />MAILING or ST EET ADDRESS <br />MAILING or STREET ADDRESS <br />0 INDIVIDUAL 0 COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE PHONE A, WITH AREA CODE <br />Rx64 <br />CITY NAME <br />1 <br />Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />NAMES//i' <br />CARE OF ADDRESS INFORMATION <br />CC ��W <br />( <br />d.57 <br />ACILITY I ( R of TANKS B7 SITE ' <br />L d a <br />MAILING or STREET ADDRESS <br />✓ Box to indicate 0 PARTNERSHIP 0 STATE -AGENCY <br />APP <br />❑ CORPORATION 0 LOCAL -AGENCY 0 FEDERALAGENCY <br />PERMIT N <br />0 INDIVIDUAL 0 COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE PHONE N. 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. ❑ it. iZ III. ❑ <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 8 SIGNATURE) DATE <br />LOCAL AGENCY USE ONLY <br />COUNTY R <br />JURISDICTION R <br />AGENCY S <br />ACILITY I ( R of TANKS B7 SITE ' <br />L d a <br />AL AGENCY FACILITY ID ♦ <br />�7cvtlfuLo\ <br />APP <br />ME PHONE F WITH AREA CODE <br />PERMIT N <br />APPROVAL DATE <br />PERMIT EXPIRATION DATE <br />LOCATIO/Lf CODE <br />e <br />CENSUS TRACT♦ <br />2 3. J 3 <br />SUPERVISOR -DISTRICT CODE <br />1 G <br />BUSINESSPLAN FILED <br />YES NO <br />DATE FILED <br />CTT• <br />GXECK Y <br />PERMIT AMOUNT <br />SURCHARGE AMOUNT <br />FEE CODE <br />RECEIPT N <br />BY: <br />THIS FORM MUST BE ACCOWANI,(E�D BY AT LEAST (1) OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br />