Laserfiche WebLink
STATE OF CALIFORNI WATER RESOURCES CONTR LBOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SRE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) ift/# 093 -/SO - <br /> FACILITY/SITE NAME I CARE OF ADDRESS INFORMATION <br /> /le ,, acl. -E ur+a6le G(fe eICA <br /> r�oQ <br /> ADDRESS N EST SS STREET ✓Barb idxge ❑ PMNDYNP ❑ STATE A090 <br /> 9 OJv ❑ COWORATON ❑ LOCALAGBO ❑ ROEPALACENw <br /> ❑ NIOMOOAL ❑ CO)NTY-AMCY <br /> CITY NAME - STAZIP CODE SITE P ONE N,WITH AREA CODE <br /> N P <br /> 1A 2 -3s5 G <br /> TYPE OF BUSINESS: ❑ ISTRIBUTOR ❑/PROCESSOR ✓Box IfINDIAN EPA to w <br /> RESEVATION❑ I GAS STATION 3 FARM ❑5 OTHER TRUST LANDS er ❑ AT THIIS SITE / <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 c 730 <br /> e Zo - -35—� Xnsll <br /> NIGHTS: NAME(LAST,FIRSFr) PHONE N WITH AREA CODE NIGHTS:-NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNERI INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE PF ADDRESS INFORMATION <br /> irlIF <br /> / L,�e N/il am is <br /> MAILING a STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> SU) f aO �Q��D �p/ I] CORPORATION 11LOCAL-AGENCY 13FEDERAL-AGENCY <br /> J ,0 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITYNAME STATE CODE PHONE N.WITH AREA CODE <br /> /vuf Cres C' ell�_ s <br /> Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> e s <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 N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> 'CHECK (1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. 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 1 <br /> COUNTY N JURISDICTION N AGENCYN FACILITY ID-F— 1 ( ko1TANKSe1SITE <br /> LOCAL AGENCY FACILITYID N APPROVED B PRONE N WITH AREA CODE <br /> PERMIT APPROV PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT It SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> .?3 P 3 � YES NO <br /> LCNEC N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> 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 /> FORMA(3@-88) ^� � • <br />