Laserfiche WebLink
STATE OF CALIFORNIAD WATER RESOURCES CONTROSOARD SIb43 <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM -''r�'t� _ 0 <br /> - <br /> SITE ,� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' � 10 <br /> LJ COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 1" <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE D7 <br /> 1 Q0 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CF) <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 6 _ Q Lt v/G?' Co C' <br /> ADDRESS NEAREST CROSS STREET ✓ Nnb Cl EBSI <br /> PANTNIP 0 STATE AGENCY <br /> �Y ` IPOPATION 0 LOCAL-AGENCY 0 FEOFPAL AGENCY <br /> of (p e U� ❑ ixomouu ❑ cauNn AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> -574 C-,E,-o, CA Asa o si <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 P SSOfl ✓Box i1 INDIAN EPA ID N <br /> RESERVATION or K'N <br /> of TAN <br /> ❑ I GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ N V AlN 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 /> Co ec/ 9 <br /> Ll A.) <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> u N <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> /)6L v/�/ do Z-6t / — <br /> MAILING or STREET ADDRESS - ✓ o indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> / Q / CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> /`(/4 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> S 1v c-lc n (2 4 1 95' <br /> Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME \ CARE OF ADDRESS INFORMATION <br /> [-�Gt ✓�a/ �U Za <br /> MAILING or STREET ADDRESS ✓ to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> �q ,p CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> (/• ((-)- 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> � t✓k ., C 9sao - <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. ❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION M AGENCYA, FACILITY ID N N of TANKS at SITE <br /> 3 9 O o / 7 3 L/ o 1 0 1 0,17 <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> `JL�Aa (o <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> V x3 3 YES [:] NO [-] 3 -O G <br /> CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 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 /> \ 1 I FORM A(3-2-BB) <br /> \1U \ -• DATA PROCESSING COPY (T, • <br /> VVV <br />