Laserfiche WebLink
�_rti �r,)y-� bio-�o C;FI <br /> STATE OF CALIFORNIP WATER RESOURCES CONTROMOARD VSA <br /> FORM `A': - m <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ! <br /> e'e<IFORi\P <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWALPERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM2 INTERIM PER MIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSUREE1 <br /> 5a�„ <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OFADDRESS INFORMA � <br /> NEAREST CROSS STREET ✓Sm to inarate ARTNERSHIP ❑ STATE AGENCY (p <br /> ADDRESS ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> /� ❑ INDMDUAL ❑ dJUN1YAGENCV �yy <br /> / C/ G STATE ZIP CODE SIT PHONE k,WITH AREA CODE V <br /> CIN NAME CA S Q i <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 0 4 PROD ✓Box if INDIAN EPA ID # It of TANK's / <br /> THER RESERVATION or AT THIS SITE <br /> 1 GAS STATION 3 FARM TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> V <br /> PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGH S: NAME(LA ,FIRST) <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> UnabPa^ /ls <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ElSTATE-AGENCY <br /> n ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL [ICOUNTY-AGENCY <br /> p(l3 <br /> WITH AREA CODE <br /> CITY NAME STAT Z P C f]L���� PHONE N, <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED))) <br /> CARE OF ADDRESS INFORMATION <br /> NAME ZE <br /> MAILING or STREET ADDRESS ✓Boz to RATIIO ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION 0 OUNTY AGE CY ClFEDERAL-AGENCY <br /> El NDIV D <br /> STATE ZIP CODE PHONE#.WITH AREA 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: <br /> 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 /> COUNTY# JURISDICTION k AGENCY# FACILITY ID k #01 TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID M <br /> APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION GATE <br /> LOCATION C DE CENSUS TRACT N SUPERVISOR-DIS RICT CODE BUSINESS PLAN FILED DATE FILFrs <br /> U f (�/ YES [j NO ❑ 3 a kq A, <br /> CHECK# <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT F BY: <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 /> FORM3-2-SB) <br /> l�U� DATA PROCESSING COPY <br /> Q ` — <br />