Laserfiche WebLink
STATE OF CALIFORA WATER RESOURCES CONTROL BOARD <br /> 5�p1 O <br /> FORM `A': s <br /> SITE UNDERGROUND STORAGE TANK PROGRAM FACILITY/SITE, <br /> Y/SITE, INFORMATION and/or PERMIT APPLICATION <br /> �.;• Io <br /> _' COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> FMARK ONLY ❑ 1 NEW PERMIT �3RENEWAL PERMIT CHANGEOFINFORMATION o <br /> ONE ITEM 2 INTERIM PERMIT 7 PERMANENTLY CLOSED SITE ~ <br /> 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) Ca <br /> to <br /> FACILITY/SITE NAME w <br /> I /> CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> /yw NEAREST CROSS STREET ✓lI lolnd Nr CI PARTNERSHIP <br /> ID STATE AGENCY <br /> ❑ GDAP1N ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> CITY NAME ❑ INDNIOUAI ❑ COUNIYAGENCY <br /> STATE ZIP CODE SITE PHONE It WITH AREA CODE <br /> TYPE OF BUSINESS 2 CA ` v <br /> DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> 0 1 GAS STATION RM F__l S"- RESERVATION or ❑ #of TANK's <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS <br /> ✓box to inUicale ❑ PARTNERSHIP ❑ STATEAGENCY❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCYCITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to in0icale ❑ PARTNERSHIP <br /> ❑ CORPORATION ❑ LOCALAGENCY <br /> STATEAGENCY <br /> ❑ INDIVIDUAL ❑ FEDERAL-AGENCY <br /> CITY NAME ❑ COUNTY-AGENCY <br /> 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. D it. [0:1Ill.THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, I S TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION Of AGENCY# �\ <br /> F ID# If Of TANKS at SITE <br /> Z 57 <br /> CURRENT LOCP AGENCY FACILITY ID <br /> S APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMITAPPR ALDATE <br /> ---- - PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> ZZ DATE FI�L/ED`�/�¢� <br /> CHECK# PEoMIT AMOUNT YES ❑ NO ❑ S' ! T L.> / <br /> SURCHARGEAM NT FEE CODE RECEIPT# <br /> BY: <br /> THISFORMMUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> 1 FORM A(3-2-88) (/p <br />\\\V\VII DATA PROCESSING COPY \ <br />