Laserfiche WebLink
STATE OF CALIFORNIAP WATER RESOURCES CONTROL0ARD <br /> FORM 'A': � ;- - <br /> UNDERGROUND STORAGE TANK PROGRAM z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ,o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> �'°Uron NSP <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F-16 <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —I <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) A <br /> FACILITY/SITE NAMEr <br /> CARE OF AD RESS INFORMATION <br /> � <br /> ADDRESS ��''I � ] �,(� NEAREST CROSS ST�RE5lT ✓&A to inLical, 0 PARTNERSHIP 0 STATE AGENCY <br /> JL4(y LI V e U Yt/T.... _ DRVDRA`ION ❑ COUNTY <br /> LOCAL AGENCY <br /> ❑ FEDERAL <br /> CITY NAME STATE ZIP ODE WOI SITE PHONE AREA CODE <br /> CA �s�40 o iQa o <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 Piq9ESSOR ✓SO. <br /> if INDIAN EPA ID a <br /> ❑ 1 GAS STATION ❑ of TANK's <br /> 3 FARM 5 OTHER RRUSTVLANDS Or ❑ v AT HIS SITE O� <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to odlCate 0 PARTNERSHIP Cl STATE AGENCY <br /> 0 CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box t.,,,doate 0 PARTNERSHIP 0 STATEAGENCY❑ CORPORATION 0 LOCALAGENCY0 FEDERALAGENCY❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE A.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. 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 N AGENCY N FACILITY ID R N of TANKS at SITE <br /> ® � �] I q 10ar I 3 -700 oJ <br /> CURRENT LOCAL AGENCY FACILITY ID x CI'l A1� APPROVED BY NAME PHONE#WITH AREA CODE 1 ��-( <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA TIQ(/CODE CENSUS TRACT# SUPERVISOR-DISTRI CODE BUSINESS PLAN FILED DATE FILED <br /> (_]1(Tl � L41 <br /> YES NO � <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEWT# BY: <br /> HIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS HIS IS A CHANGE OF SITE INFORMATION 0 <br /> FOR A(3-2-83) <br /> DATA PROCESSING COPY <br />