Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> �SE,'` 'xryf <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �" <br /> SITE FACT TY/SITE, INFORMATION and/or PERMIT APPLICATION C) <br /> COMPLETE THIS FORM FOR EACH FAC /SITE `'�nga"`" <br /> MARK ONLY T NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ TLV CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I U <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) Ul <br /> A <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS X NEAREST CROSS STREET I/Sm ibink ❑ PAATNEASHIP ❑ STATE AGDO <br /> ❑ WTRORATON ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> ❑ INOMWAL ❑ COUNTY AGENCY <br /> CITY NAME _, STATE ZIP C DE SITE PHOyl:IF WITH AREA CODE <br /> CA S <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ROCESSOR I ✓ ox if INDIAN EPA IDN Xof TANK1 <br /> ❑ 1 GAS STATION ❑3 FARM 5 OTHER RESERVATION or TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAME fLAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> !Cr B xel • 20 <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 indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODEPHONE If WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box teinaicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY it <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. ❑ if. ❑ 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 N JURISDICTION X AGENCY X FACILITY IDX X of TANKS at SITE <br /> CURRENT LOCAL AGENCYF LITY ION APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICTC DE BUSINESSPUN FILED NO ❑ DATE FILED— /' <br /> O !/ Z V <br /> CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE REGEIPTN 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 ON <br /> FORM A(3-2-SS) <br /> DATA PROCESSING COPY `✓ <br />