Laserfiche WebLink
STATE OF CALIFORJ WATER RESOURCES CONTRG*OARD .z�� `"E\ <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE J FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE "A,.oa 'o, <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PE LOSED SITE FJ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE -F� rf 00V <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) 'J <br /> FACILITY/SITE NAM {,, CARE OFA DRESS INFORMATI <br /> oil re l ( fya1 Jl S ti 1 J <br /> ADDRESS ,/'� NEAREST ROSS STREET �U1 ✓Ba�prdipk ❑ PARTNERSHIP ❑ STATE AGENCY <br /> 3 05 ILA) A A't .L7'EOHP=.N ❑ LOX AGENCY ❑ FEDERAL AGENCY <br /> V ❑ INDMDIIAL ❑ OGGNTY.AGENCY <br /> CITY NAME STATE ZIP ODE SITE PHONE A,WITH AREA CODE <br /> cA Sa�IU a �( <br /> TYPE OF BUS SS: ❑ 2DISTRISUiOR ❑ 4PROCESSOR ✓Sox it INDIAN EPA ID # <br /> GAS STATION ❑ 3FARM ❑ 5OTHER TRUSTYATION LANDSo ❑ ##1TAN <br /> AT THIS SI SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. N E(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS'. NAVE(LAST,FIR ) PHONE#WITH AREX CODE NIGHTS'. NAME(LAST FIRST) PHONE#WITH AREA CODE <br /> 5teu� N <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME r" I n ,^ - CARE OF y9DRESS INFORMATION <br /> MAILING oaror STREET ADDRESS , ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> / I ' ZF�yA ❑ Cgj1PORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCYv— L , f�`Y-- NDIVI DUAL ❑ COUNTY-AGENCY <br /> CITY NAME ST ZIP CODE PHONE#,WITH AREA CODE <br /> l� 0 ' Wa <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) - <br /> NAMEF( •V L CARE OF ADDRESS INFORMATION <br /> vV v�5 Y <br /> MAILING or STREET ADDRESS t ✓80x to indicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> �L!! l�J -KDIV[DUAL ❑ COUNTYAGENCY <br /> CITY NAME STATf ZIP ODE_ PHONE#,WITH AREA CODE T <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. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 3m = 3s <br /> CURRENT LOCAL AGENCY FACILI IO# I V✓ APPROVED BY NAME PHONE#WITH AREA CODE <br /> ep- <br /> Pin <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT_L SUPERVISOR-DIST CODE BUSINESS PLAN FILED D T FILED <br /> O� YES NO I I 0 <br /> CHECK# 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 /> FORM A(3-2-88) • <br /> DATA PROCESSING COPY <br />