Laserfiche WebLink
_. _...+ ;...�, asaWpxrRla ( ;.::__ .-..:-; -' ..,wry .-,.:.T .. 7..-ny,.•..IyYay.....,.,y.-..� <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD z` \ <br /> I <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> S1 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT IiMF5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE �{ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) W <br /> W <br /> IA TE NAME CARE OF ADDRESS INFORMATION <br /> U � u <br /> ADDRESS NEAREST CR SS STREET ✓Borbidkab ❑ PARTNEIIP 0 STATE AGENCY r <br /> c. 0 CORPDNATIGN 0 LOX AGENCY 0 EEDEIVL AGENCY <br /> 0 INDMDUAL 0 CGIINTY-AGENCY <br /> CITU NAME ,,/ -1 STATE CODE SITE PHONE X,WITH AREA CODE <br /> s , YT�iL� CA 05 <br /> dp - <br /> TYPE OF BUSINESS. ❑2 DISTRIBUTOR ❑ 4 PROCESSOfl ✓Box if INDIAN EPA ID X <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER RESERof TANKs <br /> TRUSTYLANDS ATION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS- NAME(LAST,FIR ) PHONE Al WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> a - a <br /> NIGHTS: AM ST,FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE X WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓8ox toin4icate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE X,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indwate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If,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: 1. ❑ 11. ❑ If.❑ <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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY X JURISDICTION X AGENCY R FACILITY ID If X of TANKS at SITE <br /> 00 11 = o 000 <br /> CURRENT LOCAL AGENCY FACILITY IDX APPROVED BY NAME PHONE X WITH AREA CODE <br /> O1-4— <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIONCODE CENSUSTRACTX SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> a �-- <br /> YES [_ NO lovio <br /> CHECK X PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT X T: <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 /> FORMA(3-2-88) - - <br /> ,n DATA PROCESSING COPY _�.../ <br />