Laserfiche WebLink
STATE OF CALIFORNR WATER RESOURCES CONTROL <br /> FORM `A': ` <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> 01/ COMPLETE THIS FORM FOR EACH FACILITY/SITE °"�IFOpNt" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT U�5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE x <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS -(MUST BE COMPLETED) <br /> FACILI /SITE NAME CARE OF ADDRESS INFORMATION will <br /> ADDRESS I NEAREST CROSS STREET ✓Bmbinshma ❑ PIATIRMIP ❑ STATE AGENCY <br /> ❑ CCBPOPABON ❑ LOCk AGENLY ❑ FEDEW AGE10 <br /> L ❑ INDMDLIL ❑ WUNIYAGFXLY <br /> CITY NAME STATE ZIP CODE SITE PHONE q,WITH AREA CODE <br /> CA �2-� <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> RESERVATION orX of TANK'1 <br /> ❑ 1 GASSTATION [—]3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N 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 or STREET ADDRESS ✓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 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 /> 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 If AGENCY* FACILITY ID* *of TANKS e1 SITE <br /> CURRENT��LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERR NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> [CHECK <br /> CATION COTE CENB�TRRRACY If _ SUPERVISOR-DISTRICT CODE BUSINESS PUN NO ❑ DATE FILE <br /> ES <br /> * PERMIT AM✓✓OUNTCJ�/`�J SURCHARGEAMOUNTFEECODE RECEIPT If Y: <br /> . I THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. C <br /> W FORM A(3-2-68) . J1 <br /> I � fAc) DATA PROCESSING COPY <br />