Laserfiche WebLink
I <br /> STATE OF CALIFORNI/d' WATER RESOURCES CONTROL BOARD <br /> FORM IA': <br /> UNDERGROUND STORAGE TANK PROGRAM o Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION l o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 .J <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) m <br /> IV <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> FarrnS <br /> ADDRESS NEAREST CROSS STREET ✓Barb- -❑ PARTNERSHIP ❑ STATE AGENCY <br /> / / P ' ,/' ❑ TION ❑ LOX AGENCY ❑ FEDEWIAGENCY <br /> (�/(l_-- NDMDUAL ❑ COUNTY AGENCY <br /> CITY NAMEl �; STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> (_D y 7 sd YO <br /> TYPE OF BUSINESS p 01 OR 4 PROCESSOR ✓Box if INDIAN EPA IDN / / N of TANK'N <br /> ❑ ❑ 5 OTHER RESERVATION or ❑ 1/C C ATTHIS SITE (/ / <br /> ❑ t GAS STATION FARM ❑ LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> S/,# r _ <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> erc/e/pt'Iu 5rn 7 <br /> MAILING or STREET ADDRESS ✓Box to to ❑ PARTNERSHIP Cl STATE-AGENCY <br /> / v L ❑ ORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ! <br /> 7 � 1 T y/C /!1�/I F( NDMDUAL ❑ COUNTY <br /> -AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p.WITH AREA CODE <br /> Lod; A %�a(to "g- <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S /4 , <br /> MAILING or STREET ADDRESS ✓Box 1 care ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ PORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> III. ❑ <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. Cj 11. <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 N JURISDICTION N AGENCY k FACILITY ID N N of TANKS at SITE <br /> 3 -?- ( 1010101 / <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> 0i6—r— 1E� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR DISTRICT CODE BUSINESS Y PLAN FILED NO ❑ DATE FILED_ <br /> ILII Y CHECKN PERMIT AM^jOON3 SURCXAR3E AMOUNT FEE CODE RECEIPTM BY: <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 INFORM ON ONLY, / <br /> FORM A(3-2-88) \'I <br /> DATA PROCESSING COPY ---- <br />