Laserfiche WebLink
STATE OF CALIFOAA WATER RESOURCES COOL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE .y FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NA CARE OF ADDRESS INFORMATION <br /> ROA-w CtG�k I LGA L <br /> ADDRESS NEAREST CROSS STREET ✓ Wi�&cYB ❑ PARINEASXIp ❑ SEA7EASENOy <br /> ISI C I�UQ 11k= PON ❑ LOCPLAOD Y ❑ FEDERALAGDO <br /> ❑ INDRWAL ❑ AUNTY-AGENC/ <br /> CITY NAME STATE ZIP CODE �� SITE PHONE fl,WITH AREA CODE <br /> CA o <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> RESERVATION or K of TANK'e <br /> F-1 1 GAS STATION ❑3 FARM OTHER TRUST LANDS ❑ �_ AT THIS SITE U 1 <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 /> NIGHTS: NAME(LAST,FlRST) PHONEp 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 ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESf1FORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 1:1 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If,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. Rr II. ❑ III,❑ <br /> t <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO T4BEST BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY N FACILITY ID R B of TANKS at SITE <br /> m I N o 1b O O <br /> CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE If WITH AREA CODE <br /> O lS <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT If SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE�F�"yl�\0C) k ' /,cy <br /> or—(� YES NO CI.t.JI I • `I Ol <br /> CHECK• PERMIT OUNT SURCHARGE AMOUNT FEE CODE RECEIPTM BY: <br /> 16 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LUST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATIT <br /> FORMA(8-2-88) <br /> DATA PROCESSING COPY 40 <br /> Jam_ <br />