Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or/PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EAC AGILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 015 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) C) <br /> 4 <br /> FACILITY/SITE E CARE OF ADDRESS INFORMATION <br /> D / / <br /> ADDRESS NEAREST CROSS STREET ✓Bxmlo N ❑ PAICNE&IP ❑ STATE AGENCY <br /> Cd�1UA_IX1 O LCD AGFNGY ❑ FEOER4-AGENLI' <br /> TfAGENCY <br /> CITY NAME T STATE ZIP CODE ��NGI1'INI SITE PHONE p,WITH AREA CODE <br /> CA 533 <br /> TANK'# <br /> TYPE OF BUSINESS: 2 IRESERVATION or SfRIBUTOR F__] 4 PROCESSOR ✓Box if INDIAN EPA ID Al <br /> x of <br /> ❑ IGAS STATION 2/3 FARM ❑5OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAMED CARE OF ADDRESS INFORMATION <br /> /\\\f <br /> MAILING or STREET ADDRESS ✓Box Loi tlicale ❑ PARTNERSHIP 11 STATE-AGENCY <br /> 8 13 C( RATION ❑ LOCAL-AGENCY ElFEDEHAL-AGENCY <br /> GYIRDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU AME tA STA ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME C _ CARE OF ADDRESS INFORMATION <br /> cJ <br /> MAILING or STREET ADDRESS i✓RpxtO intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> r- ❑ 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)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ IL 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY S FACILITY ID R R of TANKS at SITE <br /> QEUI = = 1 1 14= <br /> CURRENT LOCAL AGENCY�FACILITY IDM APPROVED BYNAME PHONE N WITH AREA CODE <br /> ���f� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TR�N SUPERVISOR-DISTRICT CODE BUSINESS PLAN❑FILED NO ❑ DATA FILFiD <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# U/J•, <br /> r 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 /> Wf FORM A(3-2-BS) <br /> \ i.r DATA PROCESSING COPY -Of <br />