Laserfiche WebLink
NEW <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROAARD <br /> se"` rti <br /> s f J. V• s <br /> FORM A : UNDERGROUND STORAGE TANK PROGRAM 7 �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> L . <br /> COMPLETE THIS FORM FOR EACH FA LITY/SITE k,Foaa`" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 E NTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/ ITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS 17_ NEAREST CROSS STREET ✓BNxb Minae ❑ PAATNEASNIP ❑ STATEACFNCV <br /> G ❑11 CORPINDORAALON ❑ LOOUNry AGENCY <br /> 0 FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> aG CA ao9 � - d'U <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 P ESSOR ✓Box if INDIAN EPA ID a <br /> ❑ 1 GAS STATION 3 FARM OTHER RESERVATION or X o1 TANK1 <br /> ❑ TRUSTLANDS ❑ / ' 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 Al WITH AREA CODE <br /> air9,13— ri, ?a <br /> AhNIGHTS: NAMESST) �) ��H p WITH AREA CODE NIG . NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OW ER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to oYd,cale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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 /> MAILING or STREET ADDRESS ✓Box to meicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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 ADDRIEU SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 111. ❑ <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 X JURISDICTION X AGENCY X FACILITY ID X X of TANKS at SITE <br /> CURRENT LprAL AGENCY FACILITY ID N APPROVED BY NAME PHONE 41 WITH AREA CODE <br /> vi� � d <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT X SUPERVISOR-DISTRICT CODE BUSINE88 PLAN FILED DATE FILED C <br /> 3, a D-1YES NO E] <br /> CNECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# B <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'7ICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONI <br /> ORM A(3.2-88) <br /> f 0- 10 - �� <br />