Laserfiche WebLink
or�q <br /> STATE OF CALIFORNIA • WATER RESOURCES CONTROL &RD V• sj <br /> FORMA" UNDERGROUND STORAGE TANK PROGRAM ® ° <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION are,e <br /> Ct COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> I NEW PERMIT El 3 RENEWAL PERMIT <br /> © 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY � q AMENDED PERMIT 6 TEMPORARY SITE CLOSURE — <br /> ONE ITEM 2 INTERIM PERMIT <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BEDCOMPARE OFDLETED SS aMAnoN <br /> FACILITY/SITE NAME - /,[ <br /> v L� NEAREST CRO SS STREET ✓BmmiNATN Cl PAATNEAGEN Cl FIDEMLAGP! <br /> ❑ ipBpGRAEION Cl IGGALAGENGY ❑ FEGEIUL AGFNIX <br /> ADDRESS// / 0 1 ❑ GNINttAGBIp <br /> l <br /> 14/ ATE <br /> ZIP CODE SITE PHONE p,WITH AREA CODE <br /> ST <br /> CITY NAME r l CA <br /> EPA ID N Mof TANK's <br /> d PROCESSOR ✓Box it INDIAN AT THIS SITE <br /> TYPE OF BUSINESS: 2 DISTflIBtfFOR RESERVATION or <br /> I GAS STATION E 3 FARM E] 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARDYNE N W TH AREA CODE <br /> PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> DAYS'. NAME(LRST,FIRST) <br /> PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE It WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> I/Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> MAILING or STREET ADDRESS ❑ CORPORATION 0 LOCAL-AGENCY Cl FEDERAL AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> p.WITH AREA CODE <br /> STATE ZIP CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPDL ETEDMAnoN <br /> ENAME ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> REET ADDRESS 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY- AREA CODE <br /> STATE ZIP CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> AL NOTIFICATION AND BIL I <br /> ULD BE USED FOR BOTH <br /> CHECK ONE(1)BOX INDICATING WHICH RM HAS BEEN COMPLETED ABOVEDER ADDRESS SHOP OF PERJURY,AND LE THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> THIS FO DATE <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY •of TANKS et SITE <br /> IIS AIGEN�CYI�N FACILITY IDN <br /> COUNTY N JURISDICTION M <br /> m � C� U r � 3 C c� � D <br /> Ap 7ED B'N ME PHONEN WITNAREACODE <br /> CURRENT LOC AL*GEN GALITY IDN Ff IT t/�, txF- A <br /> PERMIT NUMBER <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> BUSINESS PLAN FILED DATE FI D pj/� <br /> LOCATION CODE CENSUS TRACT <br /> SUPERVISOR-DISTRICT CODE YES [] NO -zC/' <br /> SURCHARGE AMOUNT FEE CODE <br /> RECEIPT BY: <br /> CHECK• PERMIT AMOUNT <br /> sass <br /> THIS FORM MUST-E ACCOMPANIED BY AT LEAST )OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION 0 Y <br /> ORM A(3-2-88)r <br />