Laserfiche WebLink
or - <br /> STATE OF CALIFORNIO WATER RESOURCES CONTRO ARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAMn <br /> T <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 'S <br /> ,d> <br /> GA%.%l f.COMPLETE THIS FORM FOR EACH F CILITY/SITE P <br /> MARK ONL1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> Y <br /> ONE ITEM ❑ 2 INTERIM PERMIT- ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION 8 ADDRESS—(MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> / S�u.2 uti u s <br /> ADDRESS NEAREST CROSS STREET ✓iiabCGPioiae ❑ PARTNFSSYP ❑ 6fA7EACENLY <br /> / ❑ OMTON ❑ LOCALAGE10 ❑ RLM AGDO <br /> d S HAV ❑ N7MA ❑ Cf/JM AM01 <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA Z09 -599 - 307 <br /> TYPE OF BUSINESS77r: 2 DISTRIBUTOR ❑ A PROCESSOR ✓Bw if INDIAN EPA ID N S ol TANKS <br /> SERVATION <br /> El GAS STATION [713 FARM ❑ <br /> 5 OTHER TR STT LANDS o1 ❑ 1 AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(UST.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 /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 5rt "L9 <br /> MAILING or STREET ADDRESS ✓Box to imioate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY 13 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION 6 ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S4 .,v _ <br /> MAILING orSTREET ADDRESS ✓Box tomftale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ASOYE ADORES&SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ET11. ❑ IN.❑ <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(POINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY M <br /> NAME PHONE N WITH AREA CODE <br /> �/fiNfJ�� <br /> PERMIT NUOMR PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIONCODE CENSUBTRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Iq �3a3 3 ah YES ❑ No ❑ 770 <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT0 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 /> NORM (3-2 SS) C� <br />