Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD sEa,, <br /> FORM `A': ���a�•;' "- ;�; <br /> UNDERGROUND STORAGE TANK PROGRAM °"*4` '�0� <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION } � % <br /> .Id- <br /> n , COMPLETE THIS FORM FOR EACH CILITY/SITE �""`-�°"� <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> :O <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> NEY o C • NOIJE ry <br /> ADDRESS NEAREST CROSS STREET ✓H.I.,xiomi, ❑ PARTNERSHIP ❑ STATI AGENCY <br /> ❑ CORPOHAPON ❑ LOCk AGENCY ❑fF0ER4LAGENLY <br /> 21 J' J O. � ❑ INOIVIg1AI ❑ coNNn ACING / <br /> CITY NAME, STATE ZIP CODE SITE PHONE R.WITH AREA CODE CD <br /> ,-?-r CA NE <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR 4 PROCESSOR ✓Box it INDIAN EPA ID N If of TANK's <br /> 7 GAS STATION 3 FARM RESERVATION or ❑ AT THIS SITE <br /> 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTA RS (SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS NAME(LAST FIRST) D 0 WIT H AREA CODE <br /> 11-l. Vii. 21� 47 - 51)f <br /> NIGHTS NAME( ST,fIRSTI PHONE a WITH AREA CODE NIGHTS. NAME(LAST,FIRST) U NE R WITH AREA CODE <br /> :nAmG <br /> It. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> W.S: L_L onn)6 <br /> MAILING or STREET ADDRESS ✓Sox to indreale ❑ PARTNERSHIP ❑ STATEAGENCY <br /> C <br /> El CORPORATION ❑ LOCAL AGENCY ElDERALAGENCY <br /> 2, 5, El INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAMESTATE ZIP CODE HONE R,WITH AREA CODE <br /> `J L ^ l <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S. On L_i__ nl rJC <br /> MAILING or STREET ADDRESS %/Box to inolcale Cl 11 <br /> LISTATE-AGENCY2 El CORPORATION 11LOCALAGENCY ❑ F�LIERAL AGf.NCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE R.WITH AREA CODE /� <br /> ( S �� Q C <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: 1. 0 it. E] 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# AGENCY M FACILITY ID N IT of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID Y APPROVED BY NAME PHONE 0 WITH AREA CODE <br /> GILL ) <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F LED <br /> Z//z-/ <br /> - YES NOD 3 " <br /> CHECK# PERMIT AMOUNT SURCHARG AMOUNT FEE CODE RECEIPT# Y: <br /> \ THIS FORM MUST BE ACCOMPANIED BY AT LEAST 11)OR MORE TANK PERMIT FOR M 'Br APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL <br /> \' FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />