Laserfiche WebLink
STATE OF CALIFORNIA'► WATER RESOURCES CONTROL BOARD <br /> yEx tit <br /> Y A <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM = " N <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o. z <br /> COMPLETE THIS FORM FOR EACH F LITY/SITE �.�r.oan.r 10 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E3r5 CHANGEOF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIMPERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE o? <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> j FACILITYISITE NAME CARE OF ADDRESS INFORMATION <br /> 1 <br /> ADDRESS NEAREST CROSS STREET ✓Bmbide#k ❑ PARTNMIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY 11OERAL-AGBILY <br /> 17 C�c7 14 ❑ INDMOUAL ❑ COUNn ACBIa <br /> CITY NAME STATE ZIP CODESITE PHONE#.WITH AREA CODE <br /> /P v CA 9S3GL -s99 -yYs'-k <br /> TYPE OF BUSINESS: ❑2 DBUi011 ❑4 PROCESSOR ✓BoX#INDIAN EPA ID p 40 of <br /> ESERVATION <br /> L] 1 GAS STATION FARM ❑5 OTHER TRUST LANDS or ❑ 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#WITH AREA CODE <br /> e Ge ,v -5-"- sa <br /> NIGHTS: NAME(LAST,FIR ) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 9G. S.0 0".e <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sa'--Q <br /> MAILING or STREET ADDRESS ✓Boxjointlicate 13 PARTNERSHIP ❑ STATE-AGENCY <br /> LI j70BPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDNIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> .�GP iw k 6 <br /> MAILING or STREET ADDRESS ✓Bo tlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ RPORATION ❑ 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(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. EPr IL ❑ Ill.❑ <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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> � 9 � El I I zL <br /> RENT LOCAL AGENCY FACILITY ID# APPROVED BY PHONE#WITH AREA CODE <br /> PI PERMLIABERGAMIL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT t SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> S 3 3 YES ❑ NO [-] <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: <br /> alclo <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 ONLY. <br /> FORM A(3-2-88) ( <br /> �J I1`[n DATA PROCESSING COPY <br />