Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROLB ARD <br /> FORM A: ,.� <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE / ACI /SITE, INFORMATION and/or PERMIT APPLICATION n� z <br /> (/ COMPLETE THIS FORM FOR EACH FA ILITY/SITE `'goon M`^ <br /> 10 <br /> MARK ONLY 1 NEW PER PERMIT 5 CHANGE OF INFORMATION MA YCLOSED SITE N <br /> ONE ITEM RIM PERMIT �4 AMENDED PER T 6 TEMPORARY SITE CLOSURE / rl <br /> I. FACILITY/SI INFORMATION & ADDRESS- (MUST BE COM LETED) 00 <br /> FACILITYISITE AMCARE OFA DRESS INFORMATION Ln <br /> v, N ZLlel//[P/ <br /> ADDRESS NEARE CROSS STIR ET ✓ <br /> 4 -G ❑ COIPOMiNIN ❑ DCV <br /> LOG4 AGM ❑ FE)WAGOD <br /> CITY NAME w 1 Z6 ❑ INIWD ❑ �IIN7Y.AGENLI' <br /> �. ST E ZIP CODE � / SITE PHONE N ITH AREA CODE <br /> CA q5 f1 2a9- 2693 <br /> TYPE OF BUSINESS: DISTRIBUTOR 4 PROCESSOR ✓Box it I DIAN EPA ID N <br /> I GAS STATION S FA S OTHER RESERVATION ❑ - R0I TANK'# / <br /> TRUST AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIM EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> HTS: N¢ME(LA�FIRST)- PHONE M'J/I 4H 6 NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> �/d� E #///711 9 S 6YaD <br /> II. PROPERTY NER IN ION & DDRESS - ( BE COMPLETED) <br /> NAME 9 W N ZL— Lk5A— CARE O DDRESS INFORMATION <br /> MAILI or STREET ADDRESS ✓Boxtoin ale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> � <br /> LI/�P�T , � ❑ CORPORA ON ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ <br /> CITY INDIVIDUAL ❑ COUNTY-AGENCY <br /> ME <br /> STATE c_ <br /> — IP CODE PHONE N.WITH AREA CODE <br /> �T <br /> III. TANK OWN RMATION & ADDRESS - (MUST BE COMP ED) <br /> NAME CA DRESS INFORMATION <br /> Vvyx/.T-. Gl.f/ <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 /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. It. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> LLI <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> 0 1 / g � o <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHWAREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PEPMIT EXPIRATION DATE b <br /> LOCATION CODE CENSUSTRRAACTQN' SUPERVISOR-DISTRICT ODE BUSINESS PLAN FILED DATE D <br /> YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGEAMOUNT FEE CODE RECEIPT# BY. ,x „ <br /> L/ /'U <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST . <br /> MORE TANK PERMIT FORM 'B'APPLICATION(S), U THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> �RM <br /> A(3-2-88) <br /> ,?_ t DATA PROCIPSgflua <br />