Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> ... .,. <br /> FORM 'A': �4' 0) <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' , I0 <br /> a,.a. <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ O RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY{CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0000 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) -50 <br /> Ghia <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION J <br /> u <br /> ADDRESS NEAREST CROSS STREET ✓3m Ptnrse C PAATNET9AP Cl STATE AGE4CY <br /> ❑ COWNTION 0 LOM AGDO 0 'EERALAGDO <br /> CI '.NONDWL Cl CWN7f AGOIC( <br /> CITY NAME STATE ZIP CODE SITE PHONE M.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PRXESSOfl I ✓Box if INDIAN EPA ID 4 N of TANK's <br /> RESERVATION or ❑ AT THIS SITE <br /> ❑ I GASS(ATION ❑ 7 FARM ❑ S OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE 4 WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓90a to indicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> 0 CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS '/Box tovmIcate 0 PARTNERSHIP 0 STATE-AGENCY <br /> Cl CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> C INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4.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 /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY V JURISDICTION K AGENCY N FACILITY ID R P of TANKS At SITE <br /> CURRENT LOCAL AGENCY FACILITY ID a / APPROVED BY NAME PHONE 4 WITH AREA CODE <br /> PERMIT NUMBlR RMIT APMOVILL DATE PERMIT EXPIRATION DATE <br /> ELOCATION E14PERVISOR-DISTRICT CODE BUSINESS PLAN FILED GATE FILED <br /> YES NOI PERMIT AMOUNTRCHARGE AMOUNT FEE CODE RECEIPT♦ BY, <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1` 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 />