Laserfiche WebLink
STATE OF CALIFORNO WATER RESOURCES CONTRIPBOARD P�z`PE <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM `� ­0 <br /> Sim ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> n <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C\!FORN�P <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 CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FA ILITY/SITE NAME C E OF ADDRESS INFORMATION <br /> "79f s � ry <br /> D ESS REST CROSS STREET Box toi'ri'* El PARTNERSHIP ElSTATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY 00 <br /> 41;1IPD IJAL ❑ COUNTY-AGENCY <br /> AME STATE ODE SI HONE#,WITH AREA CODE <br /> 11,61 CA <br /> -30 c-) �3� 7 <br /> BUSINESS: F—] p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EP/A ID # #of TANK' <br /> GAS STATION ❑ 3 FARM C�.ECJfrER <br /> RESERVATION <br /> Y RUSTANI or DS ❑ / AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAY NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> WSY14w . /,ea' 2 3R— 35A-r <br /> flr`GHTS: NAME(LAST,FIR T) 0 PWONE it WITH AREA CODE TS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NA C F ADDRESS INFORMATION <br /> 7 <br /> or STREET ADDRESS ✓Box to indicate El PARTNERSHIP ElSTATE-AGENCY <br /> CORPORATION <br /> El FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 11COUNTY-AGENCY <br /> AME TE CODE E#,WITH AREA CODE <br /> I11. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> C F ADDRESS INFORMATION <br /> M G or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> NAME WE CODE WE#,WITH AREA CODE <br /> 4 <br /> IV. GAL NOTIFICATION AND BILLING ADDRESS <br /> HECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. Lgf 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 /> LOCAL AGENCY USE ONLY <br /> EECK# <br /> # JURISDICTION# AGENCY# S FACILITY ID# 3ry t of TANKS at SITE <br /> El I I ooF/7�]sL1 <br /> L AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> R T APPROVAL TE PERMIT EXPIRATION DATE <br /> LlE C TRACT# S VISOR-DISTRICT CODE BUSINESS PLAN FILED D FILED <br /> ?: YES ❑ NO"IT AMOUNT §blfCHARGE 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 /> �51 A(3-2-88) <br /> DATA PROCESSING COPY <br />