Laserfiche WebLink
STATE OF CALIFORNIll WATER RESOURCES CONTRABOARD <br /> A, <br /> FORMW: E <br /> UNDERG� z <br /> ,TUND STORAGE TANK PROGRAM <br /> SITE ACILITY/SITE, l ORMATION and/or PERMIT APPLICATION <br /> 7:6:7 COMPLETE THIS FORM FOR EACH FAp�ISITE <br /> MARK ONLY F-1 1 NEW PERMIT F__1 3 RENEWAL PERMIT E?"5CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F-16 <br /> r%) <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 00 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) 9) <br /> FACII NAME 4W CARE OF ADDRESS INFORMATION <br /> ADDRE:.� NEAREST CROSS STREET V Bw wi� 0 PAMNERSHIP 0 STATE AGENCY <br /> MWORATION 0 LOW AGENCY Cl FEDEFALAGENCY <br /> 0 INDNIDUAL D COUNTY AGENCY <br /> CITY NAME STATE SITE PHONE#WITH AREA CODE <br /> CA <br /> TYPE OF BUSINES 2 DISTRIBUTOR 47PROCEIIOI V Box if INDIAN EPA 0 4 #of TANK's <br /> Box"'ND <br /> RESERVATION <br /> F� 1 GAssTAnON —13 PRO' I <br /> F FARM ESERVA ION <br /> LET L S AT THIS SITE <br /> 5 OTHER A­TRRUSTLATNDSor 0 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAME(LAST,FIRST) PHONE ft WITH AREA CODE DAYS NAME(LAST FIRST) PHONE ft WITH AREA CODE <br /> NIGHTS NAME(LAST.FIRST) PHONE 4 WITH AREA CODE NIGHTS NAME(LAST FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING o,STREET ADDRESS Box io,,,dicate D PARTNERSHIP 0 STATE-AGENCY <br /> Cl CORPORATION 0 LOCAL-AGENCY El FEDERAL-AGENCY <br /> 11 INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE I ZIP CODE PHONE It.WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS (MUST E COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING a,STREET ADDRESS V 80.10,nd,caN, D PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY El FEDERAL-AGENCY <br /> 0 INDIVIDUAL C3 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> FCHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. El I El Ill. E] <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> IAPPLICANT S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY 10 AF of TANKS at SITE <br /> = = = Inblold <br /> CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE 0 WITH AREA CODE <br /> -7 dz <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> BUSINESS PLAN FILED __FDATE FILED <br /> YES NOE] <br /> OCAT N CODE CENSUSTRI SUPERVISOR-DISTRICT CODE <br /> C C <br /> I rEK'Ol PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THISFORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) 10 5' <br /> 0 DATA PROCESSING COPY <br />