Laserfiche WebLink
`$TATE OF CALIFORO WATER RESOURCES CONTOARD F <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; IZO <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE `'��•oa�" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 91 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I-a <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> C <br /> FACILITY/ ITE NAME CARE OF ADDRESS INFORMATION <br /> Lt ,�t(Yi/C-2 <br /> ADDRESS NEAREST CROSS STREET V 300 Ydiule 0 PAATNB911P 0 STATE AGENCY <br /> //llfl/ '! / ❑ CORPORATION ❑ LOCAL AGENCY 0 FEDERAL AGENCY <br /> b f/ 2f7 C INOMOUAL 0 COUNIY-AGENCY <br /> CITYN E STATE Z CODE SITE PHONE N.WITH AREA CODE <br /> i lcyllo. CA s'23G <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> ❑ 1 GAS STATION [:] 3 FARM ❑ 5 OTHER TRUSTYLANDS ESEVATION or ❑ 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) PHONE N WITH AREA CODE <br /> NIGHTS. NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE it WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NA CARE OF ADDRESS INFORMATION <br /> J L _e <br /> o <br /> MAILI //p-�o�;§TREE1pT ADDRESS f� /� ✓Box to indicate 0 PARTNERSHIP ❑ STATE AGENCY <br /> Cv `O 1 L.V ❑ INDIVIDUAL <br /> 11 LOCAL-AGENCY❑ COUNTY AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME ST9jE ZIP CODE PHONE p.WITH AREA CODE <br /> (� <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 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. ❑ if. 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 /> COUNTYAr JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> W = O 101 o <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE <br /> 177__r / <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICC BUSINESS PLAN FILED DATE FILED <br /> _f_ L� YES NO E] <br /> CHECK# PERMIT AMO NT v SURCHARGE AMOUNT FEE CODE flECEIPT N BY: <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 /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />