Laserfiche WebLink
STATE OF CALIFORNIAN WATER RESOURCES CONTROZL OARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑�1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCLOSED SITE <br /> ONE ITEM LJ ` INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE OZ z <br /> 1 O <br /> I.FACILITY/SITE INFORMATION &ADDRESS —(MUST BE COMPLETED) <br /> F <br /> CILI SITE NAME RE OF AD`DR�ESS NFORMATION0"DRESS NEAREST CROSS STREET ✓Dow to inFune ❑ PARMEIE111P ❑ STATE AGRXN <br /> (I„ ❑ GOPPOFATION ❑ LOGU-AGBICY AALu cc <br /> (i1Au. ❑ INDIVIDUAL ❑ CDUMK C' <br /> CITY NA; STATE ZIP CODE ITE PH NE#,WITH AREA CODE 00 <br /> CITY NAI.tE _�; CA `�Ov <br /> TYPE OFF B-U•`SSIIINESIS. ❑p DISTRIBUTOR ❑4 ROCESSOR ✓Box if INDIAN EPA ID a N M TANK,N ��(( <br /> RESERVATION or 1:1AT THIS SITE (J <br /> ❑ 1 GABSTATIDN ❑ 3 FARM 5 OTHFA TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIT) PHONE It WITH AREA CODE DAYS: ItAME(LAST,FIRST) PH E#WITH AREA CODE <br /> 2lU x(06 5� A 374f <br /> NIGHT NAMELAST,FIRST) SMPHONE#WITH AREA CODE NIG NAME(LAST,FIRST) E#WITH AREA CODE <br /> S 1A ' <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF WESS INFORMATION <br /> MAILI FA <br /> $IREET ADDRESS ✓Box to indicate 11PARTNERSHIP ElSTATE-AGENCY <br /> fT�_` ❑ CORPORATION ❑ LOCAL-AGENCY ER. AIAAGE410Y <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NA ST E ZIP C PHONE M, IiH ARFA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) J�\) <br /> NAME CARE OE5D JNFORMATION <br /> MAIL S REET ADDRESS ✓Box toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCYEDER L-AGENCY <br /> 13 INDIVIDUAL 11COUNTY-AGENCY <br /> CI A STAT I ZIPC D PHONE yyITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS I[1\ <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 /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY N FACILITY ID If If of TANKS at SITE <br /> ® = = 10D z- 6 00 10 1.3 <br /> CURRENTp AGENCY FACILITY ION A P OVE AAAI! PHONE N WITH AREA CODE <br /> L/O/ UY <br /> PERMIT NUMBER PER TAPP OVAL ATS PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# /I SUPERVISIOO'(RR--DISTRICT CODE BUSINESS PLAN FILED ❑ DAT FILE <br /> V aA VES NO <br /> ONECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# Y. <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 /> M A(3-2-08) C <br /> �' DATA PROCESSING COPY <br />