Laserfiche WebLink
STATE OF CALIFORNIAN WATER RESOURCESCONTRO4OARD "^ A <br /> FORM 'A': UNDERGROUND STORAGE'TANK PROGRAM �a <br /> SITE T FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION y <br /> tea-- COMPLETE THIS FORM FOR EACH FACILITY/SITE "•a^%'" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE M'a <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) J <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Yyl e_ C)06-',- Co F 1A 1%j, <br /> ADDRESS /) NEAREST CROSS <br /> as o I Y Uu STREET ✓awtojeme 0 PANTNENIP 0 STATEAGENO <br /> n0N El YAC ❑ EDER4AGE <br /> Y ICKdA00 COUN G <br /> CITY NAMEL.A. STATCA ZIP�O � SITE PHONE pt W I AREA CODE <br /> L_OkTYPE OF BUSINESS: ❑2 DISTIBUTOR ❑4PROCESSOR ✓Bw if INDIAN EPA IDN (�_]]ll Noll/T`ALN•lK.NLL.. <br /> ❑ 160.5 STATION F]3 FARM � 'OTHEA TRUSTRESERVLANDS or ❑ �— AT THIS SITE O v <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE WITH AREA CODE <br /> IA&-k <br /> ' <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME L CARE OF ADDRESS INFORMATIO <br /> �lt.�l IXAI� �,QY Orc'b'O ' —0&l-- -— RQ/L I.) <br /> MAILING or STREET ADDRESS ✓Box to indicate <br /> 0 PARTNERSHIP 0 STATE AGENCY <br /> T 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> e, - �J -Pe ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> j MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. ❑ it. 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 M JURISDICTION N AGENCY# FACILITY ID If K of TANKS N SITE <br /> 3 °I E= o � 1 :2= 1 od 1 a I o <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> V E.(L 4 1 a-- <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LIEK <br /> E CENSUS TTR.AC• SUPERVISOR-DISTRICT CODE BUSINESSP PLAN FILED NO ❑ DATE FILED (a <br /> 6yu L4 <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY-:` <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(i)OR MORE TANK PERMIT FORM 'B' APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) (-- <br /> I w„ DATA PROCESSING COPY \/\) <br /> w <br />