Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTRW BOARD <br /> f <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ®< o <br /> 14 COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS-(MUST BE COMPLETED) A <br /> N <br /> FACILITY/SITE NAME, CARE OF ADDRESS INFORMATION <br /> bt, AuNcLL <br /> ADDRESS NEAREST CROSS STREET ✓Bmb nEiMe C PAITNEIEW Cl STATE AGENCY <br /> //,[/`/ [/pN El CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ((// �T UU II jT ❑ INDMWAL ❑ COUNTY AGENCY <br /> CITY NAME / STATE ZIP CODE SITE PHONE k,WITH AREA CODE <br /> n <br /> TYPE OF BUSINESS: ❑ ISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N Not TANK1 <br /> I GAS STATION ❑3 FARM E] 5 OTHER TRUSTYLANDS ATIONT ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(IAST,FIRST) PHONE N WITH AREA CODE <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 ^'Zyy� n' CARE OF ADDRESS INFORMATION <br /> (.TAI//L lAn <br /> MAILING or STREET ADDRESS ✓Box to indicate C PARTNERSHIP C STATE-AGENCY <br /> ❑ CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> Cl INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME / - CARE OF ADDRESS INFORMATION <br /> Q7 <br /> MAILING or STREET ADDRESS ✓Box to Indicate C PARTNERSHIP C STATE-AGENCY <br /> C CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> C INDIVIDUAL C 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. ❑ 111.❑ <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 N JURISDICTION N AGENCY N FACILITY 10 If of TANKS at SITE <br /> ql C413 0063 <br /> CURRENT LOCAL/�GENCY FA ITr N APPROVED BY NAME PHONE N WITH AREA CODE <br /> r sm %( <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA O CODE IL CENSUS TRACTSSUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> 'L3 SO YES NO <br /> GNECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTX BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-89) <br /> UV DATA PROCESSING COPY <br />