Laserfiche WebLink
STATE OF CALIFORNO WATER RESOURCES CONTR -2OARD <br /> W <br /> 7 Ga e AID m <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> R, <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C"LIFORN.'P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE J 00 <br /> CJ1 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) -� <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> n �C <br /> ADDRESS NEAREST CROSS STR T ✓B to ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> C05 O /' ` CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> El COUNTY-AGENCY <br /> CITY NAME STATE ZI CODE SITE PHONE#,WITH AREA CODE <br /> CA 6 L 2� �1� Sy�Z <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA IDG#� n C #of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS IN or ❑ J1 b J;^ I AT THIS SITE t� <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> t m lam-.�,, - <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ►arn" ` � _ yds <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAM ( CARE OF ADDRESS INFORMATION <br /> MAI I or STREET ADDRES ✓Rllrv-indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> } '. ` { /,""x""11 � �Q .l CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> SII" I v ' r` l� ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NA—`� STAT Z <br /> OrIP CODE PHONE#,WITH AREA CODE <br /> I r nC � � <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS -./Box to indicate El PARTNERSHIP ElSTATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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# AGENCY# FACILITY ID# #of TANKS at SITE <br /> d- F-n-Fo <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> If <br /> YES <br /> T n `s <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESSN FILED NO ❑ DA ILi <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 ONL . <br /> ` 1 FORM A(3-2-88) <br /> \�J�v, DATA PROCESSING COPY <br />