Laserfiche WebLink
STATE OF CALIFORA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': y � , <br /> UNdEAGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - ! <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> Cq"fORNNP , <br /> MARK ONLY ❑ i NEW PERMIT ❑3 RENEWAL PERMIT [Er5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE n <br /> ONE ITEM ❑p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE )Y� C <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) `' Q <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> )C,/ k1a 7 wv hie _5"-, <br /> ADDRESS _ NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ',, [I CORPORATION El LOCAL AGENCY ❑ FEDERAL AGENCY <br /> / <br /> `—C./C (.! � ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE If.WITH AREA CODE <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑h�5 <br /> 4 P ESSOR */Box if INDIAN EPA IDN N of TANK's <br /> 1 GAS STATION 3 FARM OTHER RESERVATION or AT THIS SITE T❑ TRUSTLANDS ❑ `'' <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> / 1/ah _5 sfy _?y s s,��^'k-P boy-s99--?6& <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sc ' <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 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 /> 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> FPERMITNUMBER <br /> Y# JURISDICTION# AGENCY# FACILITY ID# Ld <br /> of TANKS at SITE <br /> I Tl 17' k- I <br /> c T-Tol <br /> C, I o F/ <br /> AL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> DE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO ❑PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> Y <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS IS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-IBB) <br /> DATA PROCESSING COPY <br />