Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROLOCARD „/s viti-F <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM .' ^) <br /> SITE u/ FACILITY/SITE, INFORMATION and/or PE MIT APPLICATION ti� z <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EIKCHANGE OF INFORMATION ❑ 7 Y CL SED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N <br /> 00 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION W <br /> �in/a(r✓/✓ �7G1� <br /> ADDRESS y7 /y�J I/ !NEAREESTCROSS STRREEETTy' / ✓BPI COAPdtli[ele 0 PAnWIIP 0 STATEAGENi <br /> VIP) Y//C/c.p.� ❑ ONIDUAL� ❑ CCNrNY AGENCY 0 Li 11 FEOEMIAGFNGYCITY NAME �� ZIP CODE SITE PHONE#,WITH AREA CODE <br /> 111 9536 <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 P5OCfSSOR ✓B x if INDIAN EPA ID # <br /> ❑ 1 GAS STATION ❑3 FARM Siii RESERVATION or - #of TANK'N <br /> TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#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 0 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK 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 /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> I COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> = = 2 <br /> CURRENT LOCAL AGENCY FAC jpI Y ID NU I APPROVED BY NAME PHONE Jr WITH AREA CODE <br /> lAj <br /> PERMIT NUMBER N` PERMITAPPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO E] i r/ <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> VV/� <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 /> FORM A(3-2-88) A <br /> DATA PROCESSING COPY <br /> r J�C <br />