Laserfiche WebLink
STATE OF OALIFORNO WATER RESOURCES CONTABOARD <br /> SE�� rM1e <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM °1 T ' <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT , CHANGE OF INFORMATION 7 PERMA OSED SITE I-& <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1I <br /> - ? <br /> 21_ l <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) fV <br /> FACILITY/SIE AME co <br /> CARE Op DDRESS INFORMATION <br /> ADDRE 0_r ?N_,, RST CROSS STREET ✓gpFp Ygimk ❑ PAATNEASHIP ❑ STATE AGENCY <br /> \Vit ❑ DAPORATION ❑ LOCALAGENCY ❑ FEDERALAGENGY <br /> INDNDOAL ❑ COUNTY-AGENCY <br /> CITY NAME ATE ZIP O SITE PH NE N,WITH AREA CODE <br /> dt CA ` ��L V 0 3/7 (r <br /> TYPEOPBUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> RESERVATION ora of TANK't <br /> F__11 GAS STATION ❑3 FARM OTHER TRUST LANDS ❑ L_/ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> LIN E(I-AST,FIRST) PHONE p ITH AREA CODE DAYS NAME(LAST,FIRST) PHON N WITH AREA CODE <br /> S irrL 3 If � A S <br /> NIGHTS: NAME(LAST,FIRST) PHONE p WIIH AREA CODE NIGHT NAME(LAST FIRST) PHON N WITH AREA CODE <br /> Q S i� S A ��>4 <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILINGor TREET ADDRESS ✓80x lointlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME C CARE OF ADDRESS INFORMATION <br /> O <br /> MAILING or STREET ADDRESS ✓Bax to inooate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. R5IL ❑ if. ❑ <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION Al AGENCY N FACILITY ID N N of TANKS at SITE <br /> aE 10 va = DI o 1 oq <br /> CURRENT LOCAL AGENCY FACILITY ID N APP V�Y NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER n/(AJ PERMIT APPROVAL DATE PERMIT EXPIIRRATION DATE <br /> L <br /> E CENSUS TRACTN SUPERVISOR-DISTRICTC DE BUSINESS PLAN FILED DA ILED <br /> .2__3,c60 W�A � YES ❑ NO <br /> PERMIT AMOUNT SURCHARGE ANI FEE CODE RECEIPT BY: <br /> C 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 /> �'RM A(3-2-88) <br /> DATA PROCESSING COPY <br />