Laserfiche WebLink
- .- ,--,. ,.-Tri '"•�-y-�S� �_.+ +a+'z9�"��,R�• .�_ •�-i•s,��,�f�*.r-• �C! 'vkTy�rrif+-"i^i�,-� „r ,n• _ � T�, ,, , <br /> P <br /> F CALIFORNI WATER RESOURCES CONTROL BOARD <br /> STATE O <br /> S f <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r - 2:�� to <br /> COMPLETE:THIS FORM FOR EACH FACILITY/SITE "`aP�,,> <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT HANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I'V <br /> ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> ..r <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) .... <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS /�� GFNCY <br /> NEAREST CROSS STREET I�:, BoxB�ox to kale ❑ PARTNEIRLOCAL-AGENCY <br /> ❑ STATEFEDERAL-AGENCY L►j^CURPOftATIDN Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> ,/� <br /> CA �fs2�.6 Wv-IV <br /> TYPE OF BUSINESS: F_� 2 DISTRIBUTOR 4 PROCESSOR ✓Boz 11 INDIAN EPA ID # <br /> RESERVATION <br /> ANDS or ❑ #al TANK's I <br /> 1 GAS STTRUSTATION F] 3 FARM 5 OTHER AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> rRT <br /> S: NAME(LAST,FI ST) PHONE#WITH AREA CODE NIGHTS: NAME(LA T,FIRST) PHONE P WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FECERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 11.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: C 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&SiGNATUAE) DATE - <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACIL #of TANKS at SITE <br /> CURRENT LOCAL AGENCY F:��L,A <br /> APPR O PHONE N WITH AREA CODE <br /> L )t <br /> [PERMIT NUMBER PERMIT APPR PERMIT EXPIRATION DATE <br /> CATION CODE CENSUSTRACYM SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> i1 0z 3. PC) 3�/ YES 1:1NO n_ECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N Y: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST If MORE TANK PERMIT FORM 'B'APPLICATION(S), UNWHIS ISA CHANGE OF SITE INFORMATION ON <br /> FORM A(3-2-88) q <br /> Z � L 0 DATA PROCESSING COPY <br />