Laserfiche WebLink
OF CALIFORN� WATER RESOURCES CONTROOBOARD , <br /> /AeA/ /I <br /> OF- <br /> STATE <br /> 5" •t�A <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE )Z211-FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION w ; o <br /> COMPLETE THIS FORM FOR EACH FAC LITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE __1 <br /> I-� <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) CD <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> N <br /> ADDRE 0 NEAREST CROSS STREET ✓ MOIR, ❑ pApiNERSyIP ❑ STATEAGENCY <br /> S V CORMI' TION ❑ LOCAL-AGENCY ❑ FEDERAL <br /> INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> CA 95 3 <br /> TYPE OF BUSINESS: ❑ p D IBUTOR 4 PROCESSOR Box if INDIAN EPA ID p <br /> ❑ I GAS STATION 3 FARM 5 OTHER RESERVATION or ❑ N of TANK' / <br /> ❑ TRUST LANDS AT THIS SITE 1/ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE q WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME 00N Jei9rtCCARE OF ADDRESS INFORMATION <br /> . c� <br /> MAILING or STREET ADDRESS I/Box toindicate 11 PARTNERSHIP ❑ STATE-AGENCY <br /> /�,J (//1 B ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> ❑ INDIVIDUAL ElCOUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,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 ❑ PARTNERSHIP ❑ <br /> 13 CORPORATION 11LOCAL-AGENCYLOCAL-AGENCY ❑ STATE-AGENCY <br /> L-AGENCV <br /> 11 INDIVIDUAL ElCOUNTY-AGENCYCIN NgME STATE ZIP CODE PHONE p,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. ❑ II. 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION R AGENCY N FACILI N of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE k WITH AREA CODE <br /> PERMIT NUMBER PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT <br /> IlM SUPERVISOR•DISTR CT CODE BUSINESS PLAN FILED DATEI D <br /> 3.P YES NO E3 G(j <br /> CHECK# PERMIT AMOUNT <br /> SURCHARGE A OUNT 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 A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) ' <br /> nC�- o <br /> DATA PROCESSING COPY <br />