Laserfiche WebLink
T •...�U.�K�'•.,F <br /> STATE OF CALIFORNJA4 WATER RESOURCES CONTRO OARD <br /> dal <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> / C'q CiFORi`P <br /> /,FACILITY/SITE, INFORMATION and/or PERMsT APPLICATION <br /> SITE V COMPLETE THIS FORM FOR EACH IL <br /> 7 p TLY CL <br /> 1 NEW PERMIT <br /> 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ED SITE <br /> MARK ONLY 0 4 AMENDED PERMIT 06 TEMPORARY SITE CLOSURE <br /> ONE ITEM 0 2 INTERIM PERMIT <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> FACILITY/SITE NAME � � <br /> EAREST CROSS STREET ✓Box to indicate Cl PARTNERSHIP ❑ FEDERSTATEAL-AGENCY <br /> I n ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ADDRESS / f/1 A ` �M 6/�G�J� �❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> TH <br /> STATE ZIP CQDF��/" SITPHONE N,'?H AREA E <br /> CITY NAME CA <br /> 's /f <br /> ✓Box ii INDIAN EPA ID # #of TANK <br /> C./ <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR a PROLE R AT THIS SITE <br /> RESERVATION or <br /> El 1 GAS STATION 0 3 FARM E]5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(SECONDARY) #WITH AREA CODE <br /> EMERGENCY CONTACT PERSON(PRIMARY) <br /> J ONE#WITH ARE. COD DAYS: NAME(LAST,FIRST) PHONE <br /> DAYS: M�FIRST)F7/,5I) � ( � �S <br /> PHONE#WITH AREA CODE <br /> PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAS)r.FIRST) <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> ❑ PARTNERSHIP :1 STATE-AGENCY <br /> ✓Box to cate ❑ FEDERAL-AGENCY <br /> MAILING or STREET ADDRESS ❑ CORPORATION 0 COUNTY AGENCY <br /> ❑ INDIVIDUAL PHONE#.WITH AREA CODE <br /> STATE ZIP CODE <br /> CITY NAME <br /> 111. TANK OWNE FORMATION & DDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME /^ <br /> ❑ PARTNERSHIP ClSTATE-AGENCY <br /> ✓Box to indicate Cl FEDERAL-AGENCY <br /> MAILING or STREET ADDRESS <br /> [I CORPORATION ❑ LOCAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> PHONE#,WITH AREA CODE <br /> STATE ZIP CODE <br /> CITY NAME <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, <br /> TE DGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY #of TANKS at SITE <br /> FACILITY ID# <br /> AGENCY# <br /> COUNTY* JURISDICTION# 4L <br /> E= <br /> F3E E#WITH AREA CODE <br /> APPROVED BY NAME <br /> CURRENT LOCAL AG��FACILITY I�# ' <br /> PERMIT NUMBER 1/`/—`J.� PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> BUSINESS PLAN FILED DATE FILED <br /> LOCATION CODE CENSA <br /> SUPERVISOR-DISTRICT CODE YES NO - <br /> RECEIPT# <br /> CHECK# PERMIT AMOUNT <br /> SURCHARGE AMOUNT FEE CODE ul/ � <br /> IS FORM MW BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FO M A('3-Q2- <br /> 1 IWl <br />