Laserfiche WebLink
,� or <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL %RD <br /> FORM W: <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> �1llI0e N,x." <br /> �._ COMPLETE THIS FORM FOR EACH FA LLITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY OSED SITE <br /> ONE ITEM 2 INTERIM PERMIT a AMENDED PERMIT 6 TEMPORARY SITE CLOSURE S3 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 1 <br /> M xf, _ <br /> AGGRESS NEAREST CROSS STREET ❑�wvxOwIION O Lock 8 ��ACDIM <br /> ❑ NOYWN ❑ CONN-AGDIC! <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> un ca—PBOCE CA <br /> TYPE OF RUSINE$$ Z DISTRIBUTOR / $SDR ✓Box it INDIAN EPA ID N Y YI TANK'N <br /> 9-` r❑L—I +/ flESERVA7ION or ❑ AT THIS SITE <br /> 1(tGAS STATION �3 FARM OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING a STREET ADORESS' ✓Box b iiMi ate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> L.1A1 CARE OF ADDRESS INFORMATION <br /> MAILING a STREET ADDRESS ✓Box to.ncs.le Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOGAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR DOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. M 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYA, JURISDICTION Y AGENCY Y FACILITY IDS Y o1 TANKS at SITE <br /> 3 9 O O y 3 O I C) 1 o 1 0 <br /> CURRENT LOCAL AGENCY FACILITY ID Y APPROVED BY NAME PHONE Y WITH AREA CODE <br /> PERMIT NLNMER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT Y SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE PRAD <br /> c( A 3 d'D 3 \-(o YES ElNo � /d-ho <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY. Cc, <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM IBS APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> 1 WHMAIL2 tltll <br /> Acl <br /> v�`' <br />