Laserfiche WebLink
to m <br /> STATE OF CALIFORNIP WATER RESOURCES CONTROL BOARD <br /> FORM `A' UNDERGROUND STORAGE TANK PROGRAM <br /> o <br /> SITEC)FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION «`P o <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE ",ORS <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ p TLY CLOSED SITE IJ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El 6 TEMPORARY SITE CLOSURE —4 <br /> ..O <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) W <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> of S�ouC7o,✓ a c e <br /> ADDRESS MNEAREST CROSS STREET B.toirale 11iMPARTNERSHIP 11STATE AGENV <br /> 161 tf�r�e�' ❑ INDIVIDUALCI HAT10N Cl G ❑ FEDERALAGENCY <br /> CITY NAME 9'w STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA 9S2a7� <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bax if INDIAN EPA ID # <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER RESERVATION <br /> Yor 1-1 #of <br /> AT THINHIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME ST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> G(A,IA (Ch 1114607Ste✓ <br /> NIGHTS: NA E(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> •t (A <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME C V S-1 CIRE OF E9S MATION <br /> A x <br /> MAILING or STREET ADDI Box tointlicate ❑ ARTNERSHIP ❑ STATEAGENCYZSR N DO•� — ❑ <br /> CORPORATION <br /> ❑ FEDERALAGENCY <br /> INDIVIDUAL COUNT AGENCY <br /> GIN NAME STATE ZIP <br /> CODE <br /> S'Za� PHONE 4,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 irid,cate ARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL 6 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. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# At of TANKS at SITE <br /> F-;Fl-1 = = I offk 1 O (7v <br /> CURRENT LOCAL AGENCY FACT Y ID# APPROVED BYMAME PHONE#WITH AREA CODE <br /> J.c 22 <br /> PERMIT NUMBER ItPERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS O TRACT 41 SUPERVISOR-OISTRICT CODE BUSINESS PLAN FILED DATE FILED p Z Q (� YES E] NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-BB) <br /> DATA PROCESSING COPY <br />