Laserfiche WebLink
STATE OF CALIFORN10 WATER RESOURCES CONTRARIOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or <br /> pi <br /> APPLICATION , o <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <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 <br /> 714 a) <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) CD <br /> F-i <br /> FACILI SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS y NEAREST CROSS STREET ✓Bwloid.l, Cl PARTNERSHIP ❑ STATE AGEND <br /> El-MO / INDIVIDUAL Cl COUNTY AGENCY ❑ FEDERAL AGENCY <br /> C3 IND <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> /�Yao a� CA <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box if INDIAN EPA ID a <br /> ❑ I GAS STATION [:] 3 FARM ❑"5 OTHER TRUSTVATION LANDS or #of TANK'# <br /> ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> -20 3/- 3c9.3 <br /> NIGHTS'. NAME(JIONtT.FIRS ) PHONE q WITH AREA CODE NIGHTS: NPOE(LAST,FIRST( PHONE N WITH AREA CODE <br /> cl- <br /> II. PROPERT OW ER INFORMATION &ADDRESS — (MUST B COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I/Box to intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> t� �� Ll CORPORATION ElLOCAL-AGENCY [IFEDERAL-AGENCY <br /> ` iLJti�O'� FjI�DIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> s 1 o S^ 1 0,!f— I cao -31-30 <br /> Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to wd,cale ❑ PARTNERSHIP ❑ STATEAGENCY <br /> Q i l ✓� ❑ PERORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME ST TE ZIP CODE PHONE p,WITH AREA CODE <br /> s5a�1� 5�i 3e <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 /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 1c AD '-! <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 1 LOCATION CODE CENSUS'13TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI D �j <br /> 0 I i'-'l ( 9 YES � NO � '� � � / <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY- <br /> 1 sJ�-X 1 <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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />