Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITF, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m �� <br /> G COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERM N NTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME L CARE OF ADDRESS INFORMATION <br /> ADDRESS N REST CROSS STREET ✓& Wif6uA 0 PWrrNMIP 0 7Ai-AGENCY <br /> Q ❑ COPQuiION 0 L 0 FEDENL-AGBILY <br /> ❑ NOMDUAL NiY-AGBICY <br /> CITY NAME STATE ZIP CODE FITE PHONE It,WITH AREA CODE <br /> CA 9, <br /> 50` A <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ d PROCESSOR ✓Box if INDIAN EPA ID # 8 of TANIPF <br /> EA N <br /> E] 1 GAS STATION ❑3 FARM 5 OTHER TRUSTVLANDS or ❑ ATI SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAY NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> u.e Cao lam- 3 <br /> NIGHTS: NAME NAST FIRW j <br /> �R PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> C <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bos to intlicete 0 PARTNERSHIP 0 STATE-AGENCY <br /> 7/ E3 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> r �AVI ! 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME / STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Cl4 I 9sao�- <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADJARES9 ✓Box to,nd,,.Ie 0 PARTNERSHIP 0 STATE AGENCY <br /> 0 CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRBBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. 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 JURISDICTION M AGENCY 8 FACILITY ID M M of TANKS at SITE " <br /> 1,5) 19161 10100 <br /> CURRENT LOCAL AGENCY FA LITY I # APPROVED BY NAME PHONE#WITH AREA CODE <br /> PER Nr6R PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA ONCENBUB TAACTN� BUPERYI80R-GIB CODE BUSINEEBPSN FILED NG ❑ �� (LED <br /> CNE # M AMOUNT SURCH3GE J MOUNT FEE CODE RECEIPT# <br /> IS 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 /> — _ <br /> ZA(3-2-88) <br /> �1 1�( <br />