Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTR�BOARD <br /> FORM AA': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACT Y/SITE, INFORMATION and/or P MIT APPLICATION 'o <br /> COMPLETE THIS FORM FOR EV CILITY/SITE <br /> MARK ONLY W PERMIT ❑ 3 RENEWAL PERMIT '5 CHANGE OF INFORMATION TLY CLOSED SITE F"a <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ­4 <br /> I. FACILITY/SITE INFORMATION &ADDRESSpo <br /> — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME I CARE OF ADDRESS I FORMATION <br /> ( VI Ps2� <br /> ADDRESS n' f NEAREST CROSS STREET ✓ udiote PAAiNEAGHIP ❑ SiAiEAGENLY <br /> Y� y ' t0 PONA10N ❑ LOCAL-AGENCY ❑ FE)EML AGENCY <br /> I (/ a INDNDUAL ❑ WUNIYAGBICY <br /> CITY NAME STATE ZIP CODE SITE SITE PMONip,yJ1j11 RiA CEDE <br /> TYPE OF BUSINESS. ❑ ISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N S /ANw N W)%T6ANK1 SV <br /> ❑ I GAS STATION 3 FARM 5 OTHER RESERVATION or AT THIS SITE <br /> ❑ TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LRST,FIRST) PHONE N WITH AREA ODE DAYS: NAME(I-AST,FIRST) PHONE N WITH AREA CODE <br /> lay 3i �7S S�,.ttic <br /> NIGHTSNAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET A RESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Q e <br /> MAILING or STREET ADDRESS ✓Be.m intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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 ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 11. ❑ Ill. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY B FACILITY ID N N of TANKS at SITE <br /> ® = = I d 0 1410 1? 3 <br /> CURR.N OCAL AGENCY FACILI ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> If <br /> PERMIT NUMBER PERMIT'/J PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIONCODE CENSUSTRACTN SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> 2 2 YES NO 2 <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: <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 /> FORM A(3-2-88) , <br /> y DATA PROCESSING COPY �� <br />