Laserfiche WebLink
STATE OF CALIFORNIA �"� WATER RESOURCES CONTROL B4.AD ray; <br />FORM'A': UNDERGROUND STORAGE TANK PROGRAM <br />Y C'IIIfOR�•P <br />SST� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE CLOSED SITE <br />RA <br />OF INFORMATION 7 PER <br />VANEP I NEW PERMIT 0 3 RENEWAL PERMIT / <br />MARK ONLY 0 4 AMENDEDPERMIT 6 TEMPORARY SITE CLOSURE 1 <br />ONE ITEM � 2 INTERIM PERMIT <br />I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br />CARE OF QHESS INFORMATION <br />FACILI NAME 1T1 <br />�� • l�lRl I^"�' )-•J,�❑ coAPIOHAAnLSoITN E P❑H PLNCAAE11U#6. <br />/'TATS <br />CY <br />N REST CROSS STREETAL-AGENK <br />AGENCY <br />ADDRESSWITH AREA CODE <br />M7 Qi <br />CITY NASh <br />y <br />�7 CA <br />LaD ( EPA ID # # of TANK'B J <br />TYPE OF BUSINESS: 2 DISTRIBUTOR 0 4 PROCESSOR ✓ Boz if INDIAN pT TRIS BITE J <br />RESERVATION or <br />1 GAS STATION 3 FARM E15 OTHER TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERG NCY CONTACT PERSON (SECONDARY) <br />J�NE #WITH AREA CODE <br />DAYS: NAME(LASTFIRST) PHONE #WITH AREA CO E DAYS'. AME (LAST, FIRST) ccJJ' 3L <br />I <br />NIG S NAMST <br />FIR.) PHONEp WITH AAFAC NIGHT ANAME (LAST, FIRST) PR �# WITH AREA CODE <br />2 <br />fff II. PRO R OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br />ED QHESS INFORMATION <br />NAME <br />CORPindicate ❑ PARTNERBEN ❑ STATE -AGENCY <br />[�]/ El FEDERAL -AGENCY <br />MAILINGor STREET ADOflE35�r /�� CORPORATION ❑ LOCAL -AGENCY <br />C INDIVIDUAL ❑ COUNTY -AGENCY <br />STATE ZIP CODE PH N #, WITH AREA CODE (� <br />if rd c) O) QQ. Doo 7% Z'-3 `9 <br />III. TANK CSO, W <br />NER INFORMATION &ADDRESS — (MUST BE COMoLESSSST1 II <br />EFFDMAT oN <br />NAME ) <br />MAILING or EST ADDRESS rox to indicate ❑ PARTNERSHIP❑ STATE -AGENCY <br />RPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />DIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME„ 1 STCA•7 ZI<CT^ PV{(yJE ,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.II. 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 />1 OCAL AGENCY USE ONLY <br />COUNTY# <br />JURISDICTION# <br />AGENCY# <br />FACILITYID# <br />0 o TANKS M SITE <br />C) 10 1 f63 <br />baa 13 1 <br />CURRENT LOCAL AGENCY FACILITY ID # <br />APFIROVED V NAME <br />1 <br />PHONE # WITH AREA CODE <br />216 <br />PERMIT NUMBER <br />PERM APPR0AL ATE/(�1�U <br />Y\Y� <br />PERMIT EXPIRATION DATE <br />L C ON CODE <br />yCEN'SjUS TRACT <br />)# <br />1 i V `� <br />5 PERVIB -DISqjjTRICT CODE <br />BUSINESS PU1N FILED <br />YES El NO <br />DA E FIL / / <br />2 01 &.1 <br />_ _ <br />C CK# <br />PERMIT AMOUNT <br />SURCHARGE AMOUNT <br />FEE CODE <br />RECEIPTp <br />&Y: <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE TANK PERMIT FO RM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL Y. <br />FORMA (3 -2 -BS) <br />DATA PROCESSING COPY <br />f <br />