Laserfiche WebLink
STATE OF CALIFORA WATER RESOURCES CONTRIL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° : o <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 I� <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> CID <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST C OSS STREET ✓Bo.to Wim ❑ PARTNERSHIP ❑ STATE AGENCY <br /> n � 1 APORATON ❑ LOCkdGEMN ❑ FEDERN-AGENCY <br /> Otis <br /> .4 ( Q INDivIouAL ❑ COUNTY-AGENCY <br /> CITY NAME STATEZIP CODE SITE PHONE It,WITH AREA CODE <br /> cA 2 - 9R-2,9 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑/ ROCESSOR ✓Boa N INDIAN EPA ID N <br /> RESERVATION or Mol TANK'a <br /> ❑ I OAS STATION ❑3 FARM 5 OTHER TRUST LANDS ❑ AT THIS 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 CODE <br /> AwpRilwa N -TUT -6851 <br /> NIGHT ME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME - CA OF ADDRESS INFORMATION) <br /> MAILING or SSTTR ET ADDRESS ✓B to i dicate 11 PARTNERSHIP 11STATE-AGENCY <br /> 11 LOCAL-AGENCY <br /> 20 OJ INDIVIDUAL ON ❑ COUNTY AGENCY11 FEDERAL-AGENCY <br /> CITY NAMEng Y a' STATE ZIP ODE PHONE N,WITH AREA CODE <br /> Es 3a4 2 - -6g5/ <br /> 111. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ClS <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 ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. V 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 M JURISDICTION M AGENCY N FACILITY ID M M of TANKS at SITE <br /> 2- 3 1 g- 1.4 1 Cl oda <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE M WITH AREA CODE <br /> P18114 2d <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 1 <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 1' '�' 6 VES NO <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 89: <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(3-2-88) <br /> DATA PROCESSING COPY <br />