Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD : 'e <br /> FORM `A': .. <br /> UNDERGROUND STORAGE TANK PROGRAM =�° ^ <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `,r,.o ,a 10 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION <br /> ONE ITEM ❑ T P 7LY CLOSED SITE }i <br /> 2INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE j <br /> I. FACILITY/SITE INFORMATION & ADDRESS— ( OUST BE COMPLETED) F L <br /> FACILITY/SITE NACARE OF ADDRESS INFORMATION CD <br /> o� S7 '7�� F' l <br /> ADDRESS <br /> NEAREST CROSS STREET ✓B�xla hdicak P <br /> LsvIP 11 STATEAGENCY <br /> El GEN F,,►� �� ❑ NDNO��DN <br /> I 11 COUNi_ El FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE <br /> 6 SITE PHO If.WITAREA CODE <br /> TYPE OF BUSINESS 2 DISTRIBUTOR q p ESSDR ✓ CA �y <br /> ❑ Box it INDIAN EPA 10 p <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER RESERVATION or If of TANK's ` <br /> TRUST LANDS ❑ AT THIS SITE / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCYCONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS NAME(LAST,FIRST) JI PHONE p WITH AREA CODE <br /> moo K KO <br /> NIGHTS: NAME(IAST,FIRST i <br /> PHONE p WITH AREA CODE NIGHTS. NA (LAST,FIRST) PHONE p WITH AREA CODE <br /> SwP�e. <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME n0S CARE OF ADDRESS IINFORMgpIION/ <br /> MAILING or STREET ADDRESS ✓Box to ntliaie TNERSHIP2 CORPORATION <br /> LOCAL AGENCY ❑ FEDERALAGENCY <br /> CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STAT ZIP CODE PHONE p,WITH AREA CODE <br /> JCO <br /> D — / 2 <br /> 111. TANK OWNER INFORMATION ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> ./ CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to ineicale ❑ P 'NERSHIP <br /> ❑ CORPORATION LOCALAGENCY ❑ STATE-AGENCY <br /> ❑ INDIVIDUAL ❑ FEDERAL-AGENCY <br /> CITY NAME COUNTY-AGENCY <br /> STATE ZIP CODE PHONE p,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. ❑ If. 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYJURISDICTION <br /> JURISDICTION# AGENCY# FACILITY ID k <br /> [+—� ] O a E E #of TANKS SITE <br /> �� / <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY <br /> x- (�� N 2z 55 PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIONCODECODE CENSUS T ACT# SUPERVISOR- ISCODE BUSINESS PLAN FILED DATE FILED <br /> tI � YES [:] NO 0 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT <br /> 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 INFORMATION ON <br /> . <br /> FORMA(3-288) <br /> DATA PROCESSING COPY <br />