Laserfiche WebLink
STATE OF CALIFORNI? WATER RESOURCES CONTROBOARD <br /> Epi O <br /> 1S•'♦ 'l�'f <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM/ Z <br /> SITE 2 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE1 00 <br /> �O N <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) N <br /> FACILITY/ ITE NAME CARE OF ADDRESS INFORMATION <br /> 1 I L4 link- <br /> ADDRESS C S La NEAREST CROSS STREET /-6- <br /> toiMicte D PARTNERSHIP D STATE AGENCY <br /> ir AIDN FEDERAL AGENCYS � ni rn lfjU 11 INDIIVIDLD COTV AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> od-A" CA 45x40 zU 3 <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID q <br /> ❑ 1 GAS STATION E] 3 FARM OTHER RESERVATION or Ll #oI TANK's T U I <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRS ) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,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 ✓Box to Indicate D PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION D LOCALAGENCYD FEDERALAGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREETADDRESS ✓Box to,,dicato D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> D INDIVIDUAL D 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. Q 111. ❑ 111.❑ <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 Is AGENCY# FACILITY ID# If of TANKS at SITE <br /> U 171.3 10 12 Ll O 1 U <br /> CURRENT LOCAL AG Y,FACILITY IR* APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER L C fu•.!I PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TXACTM SUPERVISOR-D � ((,(-•/, <br /> C CODE BUSINESSY IED <br /> PLAN NO ❑ D fAyL/' O7 <br /> kF <br /> CHECK# p//�/�` PERMIT AMOUNT Of-) 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(3-2-881 J\ <br /> DATA PROCESSING COPY <br />