Laserfiche WebLink
STATE OF CALIFORNIA • WATER RESOURCES CONTROL BOARD <br /> FORM IA': _ �m\1 <br /> UNDERGROUND STORAGE TANK PROGRAM mo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE F'& <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 500 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) CO <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓SAta Youta ❑ PAFTN IP ❑ STATE AGENCY <br /> ec_ �,�CS�A. ii-I, NDIVIDMTIGN Cl COUNTY AGENCY <br /> FEDERAL <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> � - CA uA ILA <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓box if INDIAN EPA ID n _ #of TANK's //,, <br /> ❑ 1 GAS STATION ❑ 3 FARM �fJfSRHER TRUSTTMATION LANDS or ❑ �� AT THIS SITE V <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST)LL PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(UST,FIRST) PHONE 0 WITH AREA CODE NIGHTS. NAME(IAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS A/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ 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 Mdicate ❑ PARTNERSHIP Cl STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNW-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 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION Al AGENCY# FACILITY ID M #of TANKS at SITE <br /> 3 I I I J O c> 1 .1 1 1 b 1 o 1 o 1 C) <br /> ff <br /> ENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE <br /> U0l (_L_ 1 U PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR-DjISTRICT CODE BUSINESS PLAN FILED DAAITE�FILED <br /> oZ' � � _\ YES NO � `.( � (PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 ONLY. <br /> 1'(///FORMA(3-2-88) <br /> DATA PROCESSING COPY Zf <br />