Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROROARD o. <br /> . tf <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °^4ronN�F <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 N NTLY OSED 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/SITE NAME ', // CARE OF ADDRESS INFORMATION <br /> r WldS� / tP <br /> ADDRESS N RESTC OSSSTREET ✓Bwbmi 0 PARTNERSHIP ❑ STATE AGENCY <br /> ' C { f.s� ❑ CORPORATION ❑ GOALAGENCY ❑ FEDERALAGENCY <br /> CITY M <br /> ISTATE -V ZIP CODE INOIYIOUASITE PHONE❑ Op W17N AREA CODE <br /> 1a eco CA 54336 2 9.WITH <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER RESERVATION <br /> or ❑ - N of TANK'N <br /> ATTHISSITE O3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAY NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> an - - /3 ware <br /> NIGHTS: ME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER <br /> OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAM , CARE OF ADDRESS INFORMATION <br /> '(_(,/,,SIG CCS <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE it,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. it. ❑ 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 S JURISDICTION B AGENCY B FACILITY ID M M of TANKS at SITE <br /> _ Rl�l lole5l t 11 L5- 191 10 013 F3_1 <br /> CURRENTL CAL AGENCY FACILITY IDM APPROVED BY NAME PNONEN WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS T`RRQ`'AACT N SUPERVISSOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL O <br /> Z2 6 <br /> CHECKk PERMIT AMOUONT SURCNARGYOUNT FEE CODE YES ❑pECEIPTIMD ❑ BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMR FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONl <br /> `� FORM A(3-2-88I <br />