Laserfiche WebLink
STATE OF CALIFORNIP WATER RESOURCES CONTRO910ARD <br /> t zE.. .ref <br /> FORM 'A': <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 ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) I <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> A'S <br /> 4CO <br /> (ILA <br /> ADDRESS ��,,, NEAREST CROSSSTREET e1011 ale 0 PARTNERSHIP 0 STATE AGENCY <br /> F. C� U L IHowIDUA�GN O LOCAL AGENCY <br /> FEDERAL CD <br /> CITY NAME STATE ZIP CODE SITE PHONE WITH AREA CODE W <br /> CA O <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box if INDIAN EPA ID # <br /> ❑ 1 GAS STATION ❑ 3 FARM EVOTHER TRUSTYATION LANDS o ❑ ��' 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) PHON p WITH AREA CODE <br /> sc v Za - 6 ZOyr ,77 <br /> NIGHTS: N E(LAST.FIRST) PHONE I WITH AREA CODE NIGHTS. NAME(LAST,FIRST). PHONE N WITH AREA CODE <br /> )A &5 <br /> co <br /> If. PROPERTY OWNER NFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME I CARE OF ADDRESS INFORMATION <br /> ep 1`N AS GCS <br /> MAILING or STREET DRESS qq q� ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> (30__'4 <br /> 0 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ® 1 ,// ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CIN NAME STATE DECODE PHONE N,WITH AREA CODE''') <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> J us <br /> MAILING oI STREET ADDRESS ✓ ox to intlicaie 0 PARTNERSHIP 0 STATEAGENCY <br /> CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 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. ❑ 11j< <br /> I. 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# JURISDICTION# AGENCY# FACILITY ID# #o1 TANKS at SITE <br /> 0 101 Iz60 1010101-2-1 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BV NAME PHONE#WITH AREA CODE <br /> 5 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> ODE CENSUS TRACT# SUPERVISOR-D T ICT CODE BUSINESS PLAN FILED DATE FILED <br /> O q . D YES NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) . <br /> DATA PROCESSING COPY <br />