Laserfiche WebLink
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
STATE OF CALIFORNIP WATER RESOURCES CONTROPBOARD F <br /> FORM `A': (%�°�'� <br /> UNDERGROUND STORAGE TANK PROGRAMe <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -� , ! ' 10 <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE °n��.on�`" <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I"a <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 6, <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> IV <br /> FACILITY//SITE NAME CARE OF ADDRESS INFORMATION <br /> `d'. @n'1q/S IVO POS �'?V 2- <br /> ADDRESS NEAREST.CROSS STREET ✓BOK IP.Mxxii, ❑ PARTNERSHIP ❑ STATE AGENCY <br /> C �l� Cl CORPORATION ❑ LOCAL ❑ FEDERAL <br /> o N GJ/ 5 ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> 5 mk-lv.j CA 95�CL` 2 - -90656 <br /> TYPE OF BUSINESS: ❑ p ISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID n <br /> RESERVATION or #of TANK's <br /> ❑ 1 GASSTATION L.44 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA WDE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Be.to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERALAGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAM nn✓✓ CARE OF ADDRESS INFORMATION <br /> NJ <br /> MAILING.,STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl 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. v it. ❑ 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 /> COUNTY# JURISDICTION If AGENCY# FACILITY ID At If of TANKS a1 SITE <br /> �- 3rl <br /> CURRENT LOCAL AGENCY FACILITY 10# APPROVED 8Y NAME PHONE#WITH AREA CODE <br /> 1-4 60M 60 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> E CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FIVD <br /> 123111..3 3 2� YES ❑ NO 26 <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT IN BY: <br /> THIS FORM MUST BE ACCOMPA D BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORMA(3�� ' <br /> o 1`�`-b 7 . DATA PROCESSING COPY <br />