Laserfiche WebLink
STATE OF CALIFOR" WATER RESOURCES CONlftOARD <br /> A P _ <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �oJ <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ZI 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 SI E <br /> ONE ITEM ❑ 2 INTERIM PERMIT El AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ­4 <br /> w <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) A <br /> FACILITY/SITE NAME CARE OFAD RESS INFORMATION <br /> 2h,a r e m uc <br /> ADDRESS NEAREST CROSS STRE T ✓IW qn�a 0 PABTNEASHP Cl STATE AGFNLY <br /> 514 131.- LI 1Ae 1 I �, O1AfROPAiION ❑ LOCA.AGENCY ❑ FEDERAL V t V� $NpMpUAL ❑ CAUMY-AGENLY <br /> CITY NAME STATE ZIP ODE SITE PHONE N WIT.Ij AREA CODE <br /> Ar 5 ', (PQ oZ 0 <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR F-14 PROCESSOR -/Box it INDIAN EPA ID N ( /^• <br /> ❑ 0 of TANK' <br /> I GAS STATION ❑3 FARM S OTHER TRUSTYLANDS or <br /> ❑ v ATTHISS11% <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE x 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 /> MAILING w STREET ADDRESS ✓RDx 10 indicate Cl PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDREBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. El— it. ❑ 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 M JURISDICTION N AGENCY N FACILITY ID M M of TANKS at SITE <br /> 0 a 3 o I 0 I 0 I 0 <br /> CURRENT LOCAL AGENCY FACILITY IDN ^ ��I APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIj)N BOE CENSUS TRACT Ar� SUPERVISOR-DIS�IST CODE BUSINESS PLAN❑FILED ❑ DATE FILED <br /> (`��1(�:II ,`-I{ (-k1 YES NO <br /> CHECK Y PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: 113 1 <br /> �m r� <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 0 <br /> i DATA PROCESSING COPY <br />