Laserfiche WebLink
or-. <br /> STATE OF CALIFORNIP WATER RESOURCES CONTROROARD <br /> FORM `A': _ m <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE E FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FA ILITY/SITE <br /> MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERM SED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 �y <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> �v I~ C'av n/ <br /> ADDRESS ,� NEAREST CROSS STREET ✓Bm"IATIO ❑ LOGAI-AG ❑ STATEA-AGEN <br /> ❑ AAADN ❑ LOCAL-AGENCY ❑ FEDEALL-AGENCY <br /> �Yh Lincoln NDMDU'L ❑ o3uxn-ACEND <br /> STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CITY NAME CA {O`O_ — / <br /> Y/a <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 SSOR ✓Box if INDIAN EPA ID N _ Hof TANK's <br /> 5 OTHER RESERVATION or nn AT THIS SITE <br /> ❑ 1 GAS STATION ❑3 FARM TRUST LANDS ❑ G DW/7O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME�(L+AST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAM(LST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N 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' dIcate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> DIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> LOC <br /> MAILING or STREET ADDRESS KEIPORATION <br /> cate ❑ PARTNERSHIP ❑ STATE-AGENCY s�- AL ❑ OUNTYAGENCY0 LOCAL-AGENCY ❑ FEDERAL-AGENCYCITY NAME ZIP CODE PHONE N,WITH AREA CODE <br /> ?6W(0 - - a 6 <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. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY IDN // N of TANKS at SITE <br /> O 0 (O Q <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER /s' P7Fi <br /> PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT* ISTRICT CODE BUSINESS E NF❑ILED NO ❑ DATE FILO <br /> o/ 3 t3U ^JCHECK N PERMIT AMOUNT ARGE AMOUNT FEE CODE RECEIPT N BY: <br /> 4. <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 /> lbDATA PROCESSING COPY <br />