Laserfiche WebLink
( <br /> STATE OF CALIFOR O <br /> WATER RESOURCES CONTOL BOARD <br /> A <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE y FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : I o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 0-7­PERMANENTLY CLOSE ITE I"A <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILI ITE NA E CARE OF ADDRESS INFORMATION <br /> a c <br /> ADDRES NEAREST CROSS STREET ✓Aorta udiak ❑ PARTNERSHIP ❑ STATE AGENCY <br /> c _ B-TT0W0RATI0N ❑ LOCALAGENCY ❑ FEDEWAGENCY I^rlljl iW, <br /> ❑ INDIVIDUAL ❑ MUM AGENCY <br /> CITY NAMEStulA <br /> STATE ZIP DE_ � I` SITEPHO WITH E o <br /> F-1F-] LI,\VItrIN,V <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Boz it INDIAN EPA ID ft �QJlr�J1l� )\ <br /> RESERVATION or X of TANK's <br /> E] 1 GASSTATION [:] 3 FARM ❑.69TRER TRUST LANDS ❑ ATTHISSITE I <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME LAST.FIRST) PHONE WITH AREA CODE NIGHTS: NAME(IAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> yw-R <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#,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 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <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. 11. ❑ 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 At AGENCY# FACILITY ID# #of TANKS at SITE <br /> Ell I N 011 = 1016161 11 <br /> CURRENT LOC GENCY FACILITY APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER L III PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVI50 ID RICT CODE BUSINESSPUNFILED <br /> NO ❑ DATE ( 3 I' � �� <br /> CHECK# 1 PERMIT AMOUNT SURCHAA—R1lGE AMOUNT FEE CODE RECEIPT# CCLB.YLI <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST#R MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. �1 <br /> FORM A(3-2-88) J <br /> DATA PROCESSING COPY <br />