Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> /� UNDERGROUND STORAGE TANK PROGRAM <br /> SITE ! FACILITY/SITE, INFORMATION and/or PE IT APPLICATION <br /> V <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE `'��•�•"'" <br /> MARK ONLY ❑ I NEWPERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE r <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET 118mbYdmR 0 PAHTNMV Cl STATE AGDC` <br /> 0 cDwm oN 0 LOCILAGDO 0 FS)EIVL-AGENLY <br /> Cl INDMDUL 0 axArry-AGEta <br /> CITY NAME STATE ZIP CODE SITE PHONE 1,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: p IBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> RESERVATION or F of TANK'1 <br /> El GASSTATION 3 FARM ❑5 OTHER TRUST LANDS ❑ <br /> El AT THIS SITE D <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAME(UST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S" / /4 .54 i SCt iYt.F <br /> NIGHTS: NAME(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 ADDRESS ✓Box to iwicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 1.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 iWicete Cl PARTNERSHIP 0 STATE-AGENCY <br /> Cl CORPORATION 0 LOCAL-AGENCY 0 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 ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: . I. ❑ it. ❑ 111. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPUCANrS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY R FACILITY ID If Al of TANKS at SITE <br /> 0 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT At SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> 0G 3 3 2" YES � NO [] I S /q,, <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEECOOE gECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. j,— <br /> 1]-2-881 <br /> �. <br /> 7 DATA PROCESSING COPY � <br />