Laserfiche WebLink
Sex.0 xn '�f <br /> STATE OF CALIFORNIAWATER RESOURCES CONTROSIARD <br /> FORM `A': 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 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERM, TLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE gO <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESB -y-^ NEAREST CROSS STREET ✓BwlYYdY e 0 PARTNERSHIP D STATE AGENCY <br /> 6 11 fORPOR10N 11 LOCk AGENCY 1:1 FEDERAL AGENCY <br /> O le If U Cl INDNIDUAL ❑ COUNTY AGENCY <br /> CITY NASTATE ZIP CODE SITE PHONE#,WITH AREA COOS <br /> I "V. , CA a ato —D <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 P ESSOR ✓Bax if INDIAN EPA ID N <br /> Mol TANKY <br /> RESERVATION or <br /> ❑ I GAS STATION El FARM OTHER TRUST LANDS ❑ AT THIS SITE f <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LRST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS' NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate D PARTNERSHIP Cl STATE-AGENCY <br /> 0 CORPORATION D LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> D INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate Cl PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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. ❑ it. ❑ 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 E JURISDICTION R AGENCY R FACILITY ID N k of TANKS SI SITE <br /> am [� 010 1 1= 10 Ito O <br /> CURREN OCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE <br /> a <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES [-] NO I y/ <br /> CHECK♦ PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT• BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S),UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> \k FORM A(3-2-83) <br /> V <br />