Laserfiche WebLink
STATE OF CALIFORNIX WATER RESOURCES CONTRO'CBOARD ``� °� <br /> FORM ,A : UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �: 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��Forz�`" <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F-+ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) v <br /> t�1 <br /> FACILITY/SITE N CARE OF ADDRESS INFORMATION <br /> s �12L <br /> ADDRESS / NEAREST CROSS STREET ✓ rbirale ❑ PARINSISHP ❑ STATEAGEV <br /> AJ, y-(.� -< / / r C0110=IDN ❑ LOCAL+Iwo ❑ R#PAL-AGDo <br /> v- (/L[�-1 ❑ INDIVIDUAL ❑ WIIM AGENCY <br /> CRY NAME G STATE ZIP CODE SITE PHONE N,WITH EA CODE <br /> CA psi, C- <br /> TYPE OF BUSINESS: IBUTOR ❑4 PROCESSOR ✓BDX if INDIAN EPA ID X <br /> ❑ Ks <br /> f GAS STATION 3 FARM ❑ 5 OTHER TRREUSTYLA[ON or EDGf! AT TNIS SITE V/''y <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST. PHONE It WITH AREA CODE <br /> "Ic lc- <br /> NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> uc,- <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME A CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓ ox to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME S . T CARE OF ADDR INFORMATION <br /> MAILING or STREET ADDRESS ✓ ax toindicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE 11)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 20" II. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE X WITH AREA CODE <br /> PERMIT NIMIBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> /cLl� <br /> LOGTION CODE CENSUS TRACT• SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> -Z,3 Z5 31XI 1 YES 0 NO 17- <br /> r(32-88) <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> E ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> DATA PROCESSING COPY <br />