Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM- � <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ,r <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OFINFORMATION �7PERMANENTLYCLOSED SITE fVONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSUREI a, <br /> CO' <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 4:71, <br /> FACILITY/SITE N ME CARE OF ADDRESS INFORMATION <br /> ADDRESS �� / _ ]NEAREST CROSS STREET ✓Br toimed, ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 21 E QQEV EL 5T, ❑ CORPORATION ❑ IOGATAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDDAL ❑ c"Ntt AGENCYCITY NAME ZIP CODEiO SITE PHONE# WITH AREA CODE <br /> A 5'520 9 4 - 358 <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR [71 4 PROCESSOR ✓Box II INDIAN EPA ID p <br /> ❑ 1 GAS STATION ❑ 3FARM OTHER ITRUSTTVATION LANDSa ❑ ATTHISSITE Z <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It 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 ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> El INDIVIDUAL ­1 COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bax tointlicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCYEJ INDIVIDUAL 71 COUNTY-AGENCY <br /> CITU NAME STATE ZIPCODE 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. ❑ it. ❑ 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 /> mI I I / arTol <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE k WITH AREA CODE <br /> e&;IL <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> D/ oZ3 . -5Z3 YES 0 NO — —f� <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1 ORE TANK PERMIT FORM 'B'APPLICATION(S), UNL Isis A CHANGE OF SITE INFORM ION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY — <br /> L <br />