Laserfiche WebLink
STATE OF CALIFORNIP WATER RESOURCES CONTROL BOARD V <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 3 RENEWALbERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY ❑ 1 NEW PERMIT F-1S3 Z <br /> ❑6 TEMPORARY SITE CLOSURE <br /> ONE ITEM ❑ 2 INTERIMPERMIT F7A AMENDED PERMIT ✓ I C <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> FACILITY/SI NAME N <br /> NEAREST CROSS STREET ✓Bm R+draV ❑ FARTNEIRSIIP STATE AGENGY <br /> / ❑ C,DW MTDN El LOCAL AGENCY ❑ EEMML-AGOWN <br /> ADDRESS <br /> 0 INDAML ❑ COUN7 AGEND <br /> vsSTATE ZIP CODE SITE PHONE a.WITH AREA <br /> CITY NAME _ / `.A CODE <br /> �t�l]�� EPA ID a X of TANK'N <br /> TYPE OF BUSINESS'. ❑2 OISTRI(XROfl ❑<PHOCESSOP ESEPVATION or AT THIS SITE <br /> ❑ I GASSTATION ❑ 3 FARM ❑5 OTHER TRUST(ANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> \ A DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) <br /> PHONE X WITH AREA CODE <br /> PHONE p WITH AREA CODE <br /> V 1 NIGHTS'. NAME(LAST.FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(AST,FIRST) <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMERESS NAME CARE OF <br /> ✓Box toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGEN PHONE a.WITH AREA CODE <br /> CIN NAME STATE ZIP CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> ESS CARE OF AnoN <br /> NAME <br /> ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGEINGY <br /> MAILING or STREET ADDRESS ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE a.WITH AREA CODE <br /> CITU NAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> j,fyt CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. El III.El <br /> �r THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> FACILITY IDN N of TANKS at SITE <br /> COUNTY N JURISDICTION N AGENCY N J <br /> D / / D D <br /> It <br /> RRENT LOCAL AGErY FAC1 �[ APPROVED BY NAME <br /> - <br /> PHONE N WITH AREA CODE <br /> / <br /> CURRENT LOCAL AOE Y FACT IDN � �j <br /> PERMIT EXPIRATION DATE <br /> PERMIT NUMBER <br /> PERMIT APPROkak.DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> DATE FIIED <br /> YES NO El I <br /> CHECKN PERMIT AMOUNT SURCHARGE AMOUNT <br /> FEE CODE RECEIPT BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLFSTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> NO) , , 1 R <br />