Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROLARD `r A <br /> N Y <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM r0 <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION A. <br /> SITE �*LifORM�w : <br /> f COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 7 PERMANENTLY CLOSED 517E <br /> MARK ONLY ❑ NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION f <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE i <br /> 1. FACILITY/SITE INFORMATION & ADDRESS-(MUST BE COMPLETED) : <br /> CARE OF ADDRESS INFORMATION <br /> FACILlTY1SITE NAME <br /> f ✓ea 10 Mica [3HRIERSFII <br /> PAP ❑ STATE-AGENCY <br /> ADDRESS NEAREST CROSS STREET ❑ OOM MATION ❑ LOCAMA.00 [I FF�ERAI AGENCY <br /> ❑ IHOI410UAL EDCOUIIIY.AT;@ILY <br /> STATE ZIP GODE SITE PHONE d,WITH AREA COOS <br /> CITY NAME <br /> . CU'I\l CA <br /> TYPE OF BUSINESS: p ptSTRlfiUfOR Rl <br /> pR4CE5SOR ✓8ax if INDIAN EPA ID p A Of TANK'S <br /> RESERVATION or AT THIS SITE <br /> 1 GAS STATION 7 FARM 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE DAYS: NAME{LAST,FIRST) PHONE q WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE NIGHTS: NAME{LAST.FIRST) - PHONE N WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME I- CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP Cl STATE-AGENCY <br /> 17 S ���.�,�f �CJr _ [1 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> / .❑ tNDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE It,WITH AREA CODE <br /> CITY NAME <br /> 111. TANK OWNER INFORMATION &ADDRESS -- (MUST BE'COMPLETED) r <br /> NAME p <br /> CARE OF ADDRESS INFORMATION <br /> aL.( Q i J✓/tip` <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP EJ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE :PHONE it,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)SOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ U. 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 S SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY IDN N of TANKS at SITE <br /> LoI o I I 19 814 1 l0lolclo -1 <br /> i <br /> CURRENT LOCAL.AGENCY FACILITY ID• APPROVED BY NAME PHONE!WITH AREA CODE <br /> l0 <br /> PERMIT NUMBER PERMIT APPROVAL DATE. PERMIT EXInRATION DATE <br /> LOCATION CODE CENSUS TRACT• SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DA FILE <br /> z� 2-5 Q �3 YES ❑ NO [] /Ur <br /> CHECK 0 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT• BY: <br /> THIS FORA FAUST BE ACCOMPANIED BY AT LEAST(I)OR MORE TANK PERMIT FORM `B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FOAM A(3-2-88) �..• 1,01t <br /> �.. I FO <br />