Laserfiche WebLink
STATE OF CALIFOR A WATER RESOURCES CONT <br /> OL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE °"E FORN—" <br /> ARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ME <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> N <br /> FACILI ITE NAME CARE OF ADDRESS INFORMATION <br /> / r + , <br /> ADDRESS (/ NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ INDWIDUALRATION El LOCAL-AGENcy 1:1 COUNTY AGENCY ElFEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> /�I✓ CA <br /> TYPE OF BUSINESS: ❑ p TRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TAP <br /> ❑ i GAS STATION 3 FARM ❑ 5 OTHER TRUSTVLANDS ATION or ❑ <br /> 7AT THIS SITE <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 /> NIGHTS: NAME(LAST,FIRST) 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 ✓B to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> � <br /> j ❑ ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> c/ q3 ES INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 3 <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME C CARE OF ADDRESS INFORMATION <br /> U <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#,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. ❑ If. E�K 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 /> 131:� 1 1 11 1 1 1 1 1 1 Fz-/ 0 P- I R,0'1 L I I P4_ <br /> CURRENT LOCAL A,NCY FACILITyy APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LO ATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DAT FIL <br /> C 5�3 302 YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE ECEIPT CODE R # 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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY 0 <br />