Laserfiche WebLink
r o: <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE CI FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C ITE 7.{ <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE a �� <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CD <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ��✓BINJ11�tole ❑ PARTNERSHIP ❑ STATE AGENCt <br /> LJ�CORPoNATION ❑ LOCAL ❑ FEDERAL AGENCY <br /> Q CCSS INDMDUAL Cl COUNIV-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE a.WITH AREA CODE <br /> �sccclo.t CA 09- <br /> TYPE OF BUSINESS: [:] ISTRIBUTOR F__] 4 PROCESSOR -/Box if INDIAN EPA ID a <br /> RESERVATION or of TANK'# n <br /> ❑ 1 GAS STATION 3 FARM ❑ S OTHER TRUSTLANDS ❑ Le/G AT THIS SITE o1— <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) / <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> ou - f138 'aSU sat 7r <br /> NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> Se F ,.4-1 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> G1,-v <br /> MAILING or STREET ADDRESS ,,✓eo inaicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /J /J LJ JdOHPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> 5 Xh /Lq LYINDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> /9�o vP 1 vr-zr <br /> MAILING or STREET ADDRESS ✓So in'icat. ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,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. IF, 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 3 l P o a I o I )- <br /> MPERMIT <br /> LITY ID# APPROVED BY NAME + PHONE#WITH AREA CODE <br /> VAL DATE PERMIT EXPIRATION DATE <br /> TRACT# SUPERVISOR-DISTRICT CODE BUSINESS`SN FILED NO DATE FILEDMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY:: <br /> 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) / <br /> DATA PROCESSING COPY <br />