Laserfiche WebLink
STATE OF CALIFORN" WATER RESOURCES CONTR�B ARD „/,5��;•�'�F..� <br /> FORM `A': �_. _ SA <br /> UNDERGROUND STORAGE TANK PROGRAM m <br /> ,� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATI0 <br /> ON <br /> SITE FACILIT <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE -p <br /> C'a[IFO RNP <br /> EMARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT J <br /> ONE ITEM CHANGE OF INFORMATION ❑ 7 PER ENTLY CLOSED SITE I-� <br /> ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME '� <br /> ^ ' •� I CARE OF ADDRESS INFORMATION <br /> ADDRESS V <br /> 2_7 3 Q j NEAREST CROSS STREET ✓Box to icale Cl PARTNERSHIP ❑ STATE-AGENCY <br /> UU / 1" r7�i2 (/( ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME INDIVIDUAL ❑ COUNTY-AGENCY <br /> �Y STATE ZIP CODE J SITE PHONE It. ITH AREA CODE <br /> TYPE OF BUSINESS: CA <br /> ,I;OSTRIBUTOR ❑4 PROCESSOR ✓Box if INDIA EPA ID it <br /> 1 GAS STATION 3 FARM ❑ 5 OTHER ESEVATION TRUST LANDS or ❑ #of TANK's <br /> EMERGENCY CONTACT PERSON(PRIMARY) AT THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> 7^�` L_ PHONE#WITH AREA CODE <br /> NIGHTS: If NAME(LAS T,FIRF) !/`PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> E!tSTATE <br /> CARE OF ADDRESS INFORMATION <br /> ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> E ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FNAME �\ h _ eCARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,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. II. ❑ 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&SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY ID# #of TANKS at SITE <br /> ml / a=- <br /> CURRENT LOCAL AGEffff����Y FACTLLIITY ID k <br /> P� /7��� APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER /•� PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> LOCATIO CgODE CENSUS T ACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> ` Z 2- YES DATE FILED /2 <br /> / CHECK# PERMIT AMOUNT' NO l <br /> SURCHARGE AMOUNT' FEE CODE RECEIPT# <br /> 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 /> FORMA(3-2-88) � / <br /> DATA PROCESSING COPY • `---. <br />