Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD s <br /> FORM IA': UNDERGROUND STORAGE TANK PROGRAM o z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION r7l 7 PERM TLY CLOSED SITE <br /> ONE ITEM 2INTERIM PERMIT 4AMENDED PERMIT 6 TEMPORARY SITE CLOSURE —4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> L +� LLIrs <br /> ADDRESS / (y / �// / NEAREST GROSS STREET ✓WW iMiwce ❑ LOCAL-AERIPGENCY <br /> Cl FEATE DERAGENCY <br /> AGEN <br /> V1 K ❑ fAAPOFATION ❑ LOCI AGENCY ❑ FEDERAL AGENIX <br /> Cl INDIVIDUAL Cl GOUNNAGENCY <br /> CITU NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA S ZOO <br /> TYPE OF BUSINESS: 3 D UiOR 4 PROCESSOR ✓Box it INDIAN EPA ID N _ 0 of TANK's <br /> S OTHER RESERVATION or AT THIS SI7E <br /> 1 GASSTATION 3 FARM TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> �'LGr r+ir s <�ftA L f/lL <br /> NIGHTS. NAME(LAST,FIRST PHONE p WITH AREA CODE NIGHTS'. NAME(LAST,FIRST( PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to ir,dicao Cl PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERALAGENCY <br /> D INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME S <br /> Z as ✓Gox 10 Indicate D PARTNERSHIP Cl STATE AGENCY <br /> MAILING or STREET ADDRESS <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N,WITH AREA CODE <br /> CITY NAME <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. 11. ❑ 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 /> 7= <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY N FACILITY ID N If of TANKS al SITE <br /> � = ov o � o � <br /> CURRENT LOCAL AGENCY FACILITY ID N / APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER '�ZJ)N/-L'-/4..rLPECRMM`ITI/APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERV OR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES � NO <br /> CHECK#-/ PERMIT AMOUN/T SURCHARGRAMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(I)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. ' <br /> FORMA(3-2-BB) J <br /> DATA PROCESSING COPY <br />