Laserfiche WebLink
STATE OF CALIFORNIA') WATER RESOURCES CONTROL BOARD '`''` <br /> FORM `A': �: <br /> UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION "'� o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `"�noax�" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F"+ <br /> ONE ITEM ❑p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1 -4 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 00 <br /> ��// ' u�c <br /> (�/} S i,aC^ /CGE rLG <br /> ADDRESS NEAREST CROSS STREET ❑ PARTNERSHIP ❑ STATE AGENp <br /> L!I C1 7 eel L[It- Hila ❑ LOCAL-ABENcr ❑ FE)ERALMM <br /> Mows ❑ COUNn-AGENa <br /> CITY NAME STATE ZIP CODE SITE PHONEjpYW/TH AREA CODE <br /> c t 4rJYI CA i2 r <br /> TYPE OF BUSINESS'. ❑ p 55MBfITOR ❑ /PROCESSOR ✓Box i11NDIAN EPA ID # <br /> ❑ 1 GAS SiAT10N 3 fARM ❑ 5 OTHER If of TANICS <br /> TRUSTVLANDS ON Or ❑ u�� AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(UST,FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE k 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 /> a Or r5in.7 <br /> MAILING or STREET ADDRESS <br /> ✓BCox to ae ❑ PARTNERSHIP 13 STATE-AGENCY <br /> ;PWORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> p7 C `Tc>,­f_el res/ ❑ DIVIDUA ❑ COUNTY-AGENCY <br /> CITY NAME STATE DECODE PHONE M WITH AREA CODE <br /> �vcicdLv,L C/J I `IsaOS # ul <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME �` CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING or STREET ADDRESS ✓Box 'ca <br /> le ❑ PARTNERSHIP 11 STATE-AGENCY <br /> ❑ PORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE H.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTN LEGAL NOTIFICATION AND BILLING: I. ❑ I. 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# JURISDICTION R AGENCY R FACILITY ID If If of TANKS N SITE <br /> 3 % I I I Zd A O <o b c7 Ci / <br /> CURRENT LOCAL AGENCY AGILITY ID APPROVED BY NAME PHONE N WITH AREA CODE <br /> �A <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE I CENSUS TRACT A SUPERVISOR-DIS ICT CODEBUSINESS PLAN FILED DATE FILED <br /> 3 a � � YES NO �3 <br /> \,NI CHECK# tPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> V <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. j <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY i <br />