Laserfiche WebLink
STATE OF CALIFOR WATER RESOURCES CONTRBOARD <br /> FORM `A': _ a .z <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY Fr NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SIT N ME CAREOFADDRESS INFORMATION <br /> ADDRESS NEA STCSTREET ✓Bu a vMiAe ❑ PARTNERSHIP ❑ STATE AGENCY <br /> `�%AE'Jj/I_ nn'-'_ ❑ WRPOPATION 1:1LOCALAGENCY FIDEPAL AnjENLY, <br /> A W Yv Cl INDIVIDUAL ElCOUND AGENCY INF�'w� <br /> CITY NAM STATE Z C Jr p�L/ S�f NE6�A CODE <br /> ITE <br /> E 11.WITH <br /> 0,tk. CA <br /> TYPE OF BUSINESS: [:] 2 DISTRIBUTOR F_' PROCESSOR ✓Box if INDIAN EPA ID n M of TANK's D <br /> ESE <br /> F—] 1 GASSTATION F-13FARM OTHER TRUSTMATIO LANDSor ❑ ]A ATTHISSITE 9t <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> D S NAM ( ST.FIRST) PHONE N WITH AREA CODE DAYS: N ME(LAST,FIRST) PHO -ITH AREA CODE <br /> 5�7o s?Q (Al <br /> NIGHTS'. (LAST,FIRST) HONE ft WITH AREA CODE NIGHTS: AME(LAST.FIRST) PHON M WITH AREA CODE <br /> s1,� S1SIA <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME 514 CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE ft.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 Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ❑ 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 <br /> COUNTY N JURISDICTION# AGENCY M FACILITY ID N #of TANKS at SITE <br /> = = I Db 7 Isl 10 1010 Il <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY N E PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPA AL A PE MIT EXPIRATION DATE <br /> LOCALF# <br /> CENSUS TRACT# 5 PE VIS R-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> t 101 YES NO v� 1Z' F <br /> CHEPERMIT AMOUNT SURC14ARGk AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION <br /> FORMA(3-2-SR) <br /> DATA PROCESSING COPY 0 <br />