Laserfiche WebLink
STATE OF CALIFORNIk' WATER RESOURCES CONTRdeBOARD <br /> FORM 'A': <br /> SITE UNDERGROUND STORAGE TANK PROGRAM <br /> G FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION1Z <br /> o 0 <br /> COMPLETE THIS FORM FOR EACH FAC TY/SITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEYVAL PERMIT 5 CHANGE OF INFORMATION <br /> ONE ITEM ❑ 7 PERMANENTLY CLOSED SITE Is <br /> ❑2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q <br /> L FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME QjZ ;64 CARE OF ADDRESS INFORMATION <br /> ADDRESS �S C/ U u4�- - <br /> NEARESTCROSSSTREET rtivk ❑ PAHINMIF ❑ SLATE AGENCI <br /> SO e/ QO ,Zjn . A� aY CI FEDEAALAGEML <br /> CIN NAME ❑ � p cnTr <br /> STATE Z CODE SITE PHONE#WITH AREA CODE <br /> TYPEOF SINESS. T/c CA 9`ys9 a09 9Y/-dd <br /> ❑2 DISTRIBUiOfl ❑ 4 PROCESSOR ✓Box A INDIAN EPA ID a <br /> 1 GAS STATION ❑3 FARM ❑5 OTHER TRUST LANDS RESER P' ❑ /��- AT THUNICS <br /> S SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS'. NAME(LAST,FIRST) _ PHONE k WITH AREA CODE <br /> 9/// / -a37S/ f �, hto.Ls� tuo �.� 9Y/y - 9u as <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE P WITH AREA CODE <br /> 7e - f 000 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME �h -()cu O// O CARE OF ADDRESS INFORMATION <br /> `' NT A7 /lv' <br /> MAILING or STREET ADDRESS SUf f( $-O ✓ x to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> N CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> W-11/7a C, eek- <br /> III. TANK OWNER INFORMATION&ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> "0 CC( CARE OF ADDRESS INFORMATION <br /> � �o q>5ol,,p AZL r. <br /> MAILING or STREET ADDRESS ✓ to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> S —}� CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> li- ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICII ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II. 111.❑ <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 R JURISDICTION k AGENCY M FACILITY ID N M of TANKS BI SITE <br /> 3 I I I I I I I I o I v1 a lal <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE#WITH AREA CODE <br /> V010 YA <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESSPIAN FILED DATE FILED <br /> ,j YES NO <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N By; <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERM;FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> �JRM Ala-2-&B) <br /> 1iNf S� DATA PROCESSING COPY <br />