Laserfiche WebLink
w <br /> STATE OF CALIFORIRA WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PROGRAM0 <br /> � <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIO � � Z2 <br /> �q-'-ir]P <br /> v COMPLETE THIS FORM FOR EACH CILI7Y/SITE ��^""" Y C <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERM TLY CL SED SITE n <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE a' <br /> Ct <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) -- W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> (�GU�S 1vu)vor5 y,,/o <br /> ADDRESS /�^,^ /-//�' NEAREST CROSS STREET ✓Boawm ale 0 PARTNERSHIP C1 STATE AGENCY <br /> 11 -700 W' SvVVV` 1 ❑ CORPORATION ❑ LOGLAGENCf ❑ FEOERALAGENCY <br /> 0 INGMWAl 0 COUNTYAGENCY <br /> CIN NAMESTATE ZIP CODE SITE PHONE A.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIA EPA ID N <br /> RESERVATION orx of TANK'# <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS S1TE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> flp�kAi o b 111 —F ;4-9V2 <br /> NIGHT . NAME(LAST.FI T) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCALAGENCY0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY 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 ✓Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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: 1. ❑ It. ❑ 111.❑ <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(POINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYIF JURISDICTION Is AGENCY K FACILITY ID N A of TANKS at SITE <br /> 7_ = = aF1 7/ 510 ID L I <br /> CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHO ITH AREA CODE <br /> �i) <br /> rw, s <br /> PERMIT NUMBER PERMIT AP ROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECLK# <br /> CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO u <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> 3 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(SS ESS THIS IS A CHANGE OF SITE INFORMATION(7. <br /> FORM A(3-2-88)v \ <br /> \,Y DATA PROCESSING COPY �_J <br />