Laserfiche WebLink
• ''OFA... <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A,: : " AUNDERGROUND STORAGE TANK PROGRAM =`� "gym <br /> SITE[E FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION b t� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMAN ED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �V C <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME ,r CARE OF/ADRESS INFORMATION <br /> A N <br /> ADDRESS NEAREST CROSS STREET ✓Box to indicate 0PARTNERSHIP ❑ STATE-AGENCY <br /> (� /)�/J � ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FE ERA-AGENCY <br /> 7 4 �Q ❑ INDIVIDUAL ❑ COUNTY-AGENCY 00 <br /> CITY NAME STATE ZIP CODESITE PH NE#,WITH AREA CODE <br /> b t CA s +�D mil.36 <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR _ <br /> 4 PROCESSOR */Box if INDIAN EPA ID # #of TANK' <br /> RESERVATION or s �+ <br /> ❑ I GAS STATION [:] 3 FARM �5 OTHER TRUST LANDS ❑ Al A AT THIS SITE U <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAY NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAM (LAST,FIRST) PHON #WITH AREA CODE <br /> NIGHTS: N E(LAST,FIRST) PHON #WITH AREA CODE NIGHTS: f1QE(LAST,FIRST) PROT 9 WITH AREA CODE <br /> (}// <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF A �SS INFORMATION <br /> # R <br /> C <br /> MAILING or STREET ADDRESS ✓Box to indicate f7rPARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> D ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> d.4. Cry f-2- i S o4 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING&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#,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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> LoLc->] v LoLTK0 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> �c <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO� �.�{[, ld ll U <br /> CHECK# PER 1AIT AMOUNT SURCHAfl E AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS HIS IS A CHANGE OF SITE INFORMATION 0 Y. <br /> ` FORMA(3-2-88) <br /> \\\V DATA PROCESSING COPY �— <br />