Laserfiche WebLink
STATE OF CALIFORA WATER RESOURCES CONTROL BOARD <br /> �SEe�S:t:��e <br /> FORMA": °` '` � 's', <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ,; 10 <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE `'��e��"`" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) JN. <br /> F ITV/SITE AVE , M CARE OF ADDRESS INFORMATION <br /> r ' <br /> ADDRESS NEAREST CROSS STREET ✓Po idilane 0 PARTNERSHIP 0 STATE-AGENCI <br /> // APORATION 0 LOCALAGENU 0 FEDERALAGENCY <br /> -/ INOIVIOUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE a,WITH AREA CODE <br /> EsCsY am CA 20 <br /> TYPE OF BUSINESS ❑3,01STRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> ❑ <br /> 1 GAS STATION 3 FARM ❑ 5 OTHER RESERVATION or AT TNAS SITE TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS'. NAME(I-AST,FIRST) PHONE a 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 CARE OF ADDRESS INFORMATION <br /> /A)4t� <br /> MAILING or STREET ADDRESS ✓B oindicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> ORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY <br /> ON INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NA/E STATE ZIP CODE PHONE a.WITH AREA CODE <br /> 6 s�v <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME% �p / CARE OF ADDRESS INFORMATION <br /> C J <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> ❑ INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,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 /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY11, FACILITY ID R R o1 TANKS at SITE <br /> 39 ;)- 0 100 <br /> CURRENT LOCAL AGENCY FACILITYD APPROVED BY NAME PHONE N WITH AREA CODE <br /> �7�%5 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOC TION CODE CEN <br /> SUS TRACT If SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED D T IL/,/y <br /> 23.2 3 YES ❑ NO ❑ , /' C <br /> CN KN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Al BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(0 MORE TANK PERMIT FORM B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />