Laserfiche WebLink
STATE OF CiALIFORNI - WATER RESOURCES CONTR <br /> Ep Of <br /> OARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ZKCHANGE OF INFORMATION ❑ 7 PERM NT SED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 10 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRE INFORMATION <br /> r <br /> N <br /> ADDRESS NEAREST CROSS STREET U 9mlo'Mirale 0 PA EASHIP 0 STATE AGENCY <br /> 1 Cl CORPORATION 0 tO ALAGENCY 0 FEDERAL AGENCY <br /> 0/ WG ❑ INDIVIDUAL 0 COUNTYAGENCY DO <br /> CITY NAME STATE ZIP CODE SITE PHONE 4 WITH AREA CODE <br /> CA III <br /> TYPE OF SINES$: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or #of TAI <br /> GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST( PHONE#WITH AREA CODE <br /> 1 h - <br /> NIGHTS'. NAME(LAST, IRST) P NE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) HONE it WITH AREA COEFE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME A /� / CARE OF ADDRESS INFORMATION <br /> MAILING or STREEET ADDRES5�1/ ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> !„T- CyRPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> / O� UlFNDIVIDEAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODEPHONE#,WITH AREA CODE <br /> ✓ 7JY7 r� <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME � CARE OF ADDRE SINFORMATION <br /> sen Ce p <br /> MAILING or STREET ADDRESS ✓ to intlicate 17 PARTNERSHIP 0 STATEAGENCY <br /> ?��Jy CORPORATION 0 LOCALAGENCY0 FEDERALAGENCY <br /> ji SW J✓ �0— ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAMES STATE I ZIP CODE/ /`n // HO a.WITH AREA CODE <br /> V cw� L M// a / <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. ❑ 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# JURISDICTION It AGENCY# FACILITY ID If #of TANKS at SITE <br /> C) / I © d 10 1 _3 <br /> CURRENT LOCALAGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION C E CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> D � YES E] NO ❑ y/3 <br /> CHECCK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> 1 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 /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />