Laserfiche WebLink
STATE OF CALIFOAA WATER RESOURCES COOL BOARD <br /> FORMA': <br /> UNDERGROUND STORAGE TANK PROGRAM T " o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION E LY C EITE <br /> ONE ITEM ❑ Z INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE � 3 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) CDN <br /> C.T1 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET 1/80rtoirdiule ❑ PWNERSIIP ❑ STATE AGENCY <br /> ❑ CORPORATION 13LOCILAGENCY ClFEDERALAGENCY <br /> 11 INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> c CA <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR d PROCESSOR ✓Box if INDIAN EPA ID N <br /> RESE❑ If of TANK's <br /> 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTVLANDS ATION or ❑ AT7 IS 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 N WITH AREA CODE <br /> NIGHTS. NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ 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 intlicale ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ 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 ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ III. ❑ <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION As I�AGE�Y k FACILITY ID k M of TANKS at SITE <br /> G <br /> EE = C-) I A I v I c)l A 0 <br /> CURRENT 11I AGENCY FACILITY 10 a APPROVED BY NAME PHONE a WITH AREA CODE <br /> 2�6- I <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LO CODE CENSUS TRACT If SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ATE FILED <br /> oZ/ YES ❑ NO ❑ /�/ <br /> G' <br /> C CKa PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN Y: ou <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM P(3-2-88) <br /> DATA PROCESSING COPY • <br />