Laserfiche WebLink
STATE OF CALIFORN6%, WATER RESOURCES CONTROL eARD <br /> ORM A: UNDERGROUND STORAGE TANK PROGRAM �p <br /> BITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> _ MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 YCLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / <br /> FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> FACRITYMTE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS //�_ NEAREST CROSS STREET ✓I1Pbb5tIR ❑ IDEA <br /> LY0 totmwI TDY 0 LOEWY❑ NIOMDVl ❑ 1SSTATE - ZIP CODE SITE PyOyyy <br /> CITY NAME / CA 7/ // <br /> TYPE OF BUSINESS: ❑2 DISTRDUTOf( ❑1 PROCESSOR(/- ✓Dox BINDIAN EPA 10 N lh' L/ I of TANK'I <br /> ❑1 GAS STATION ❑3 FARM ❑ 5 DINER RpUTm(ANOS ION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(IAST,FIRST) PHONE M WITH AREA CODE <br /> r+ <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FAI�G <br /> CARE OF ADDRESS INFORMATION <br /> REET ADDRESS ✓Box to iw'"te D PARTNERSHIP ❑ STATE-AGENCY <br /> D CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> r' ✓Box 10 md.i to 0 PARTNERSHIP D STATE-AGENCY <br /> WILING of STREET ADDRESS 0 CORPORATION D LOCAL-AGENCY D FEDERALAGENCY <br /> D INDIVIDUAL 0 COUNTY-AGENCY <br /> GTY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> r_ <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> r. CHECK ONE(1)BOA INDICATING WHICH ABOVE ABORM SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. El 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 MME(PRINTED 8 SIGNATURE) DATE <br /> r <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION• AGENCY M FACILITY ID R 0 of TANKS Al SITE " <br /> APPROVED BY NAME PHONE I WITH MEA CODE <br /> � CURRENT LOCAL AGENCY FAGI�NaM y 33 <br /> PERMIT NUMBER PERMITAPPROVALDATE PERMIT EXPIRATION DATE <br /> r <br /> LOCATION OE CENSUS"ACT I SUPERVISOR IBTIICT CODE BUSINESSESPLANFILED NG ❑ DA <br /> PERMIT AMOUNT SUR RGE AMOUNT FEE CODE RECEIPT• BY% /� <br /> CMEGI(I 2,1 <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 /> FORM A(3-2-SS) <br /> 1 a14?.(5' <br />