Laserfiche WebLink
STATE OF CALIFORNIA* WATER RESOURCES CONTROOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION } . <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE E-0 <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT I�KCHANGE OF INFORMATION ❑ 7 PER TLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE J <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) a a <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> r <br /> ('S 15 C r� ` <br /> cz— <br /> ADDRESS NEAREST CROSS STREET ✓ L roicale ❑ PARTNERSHIP ❑ STATE-AGENGY <br /> r l f n ' CORPORATION ❑ LOCAL-AGENCY ❑ FEOERAL-AGENCY 00 <br /> D <br /> C ❑ INDIVIDUAL ❑ COUNTY-AGENCY 00 <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE +� <br /> Seo �c� CA q5,A11 a 6, a 5y;l <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑— 4 PROCESSOR ✓Box if INDIAN II��I EPA ID # <br /> ❑ ❑ L TRUST LANDS RESERVATION or I_J /� O n e_ #of TANK ,r <br /> I GAS STATION 3 FARM OTMFR AT THIS SITE I <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> f4MErN , Char I <br /> NIGHTS' NAME(LAST,FIRST) rHH`O'[N,E/#WITH AREA CODE NIGHTS_ NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> 11 tj <br /> F 4 T(Q <br /> IL PROPERTY OWNER I ORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sa-pona <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE APHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESSINFORMATICN <br /> .3cfYYle a5 S ! Le <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIOUAL ❑ 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. ❑ 11. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> ® 101-ol ° © / <br /> CURRENT LOCAL AGENCY FACILITY IVIED# APPROVED BY NAME PHONE#WITH AREA CODE <br /> lalL1 <br /> PERMIT NUMBER PERMIT APP L PERMIT EXPIRATION DATE <br /> Qb LOCATION CODE CENSUS TRACT# SUPERVISOR-DIST CT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO �g <br /> CHECK# PER T AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <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(3-2-88) _ <br /> DATA PROCESSING COPY <br />