Laserfiche WebLink
STATE OF CALIFORNIA. WATER RESOURCES CONTROL, r%OARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> / COMPLETE THIS FORM FOR EACHFA TY/SITE <br /> MARE(ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> -. FACILITY/SITE NAME ^ CARE OF ADDRESS INFORMATION <br /> ,ADDRESS i NEAREST CROSS STREET ✓Box to vdicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /CJ JO/} -�. 9 00 �q X/�e� // // ❑ CORPORATION ❑ LOCM-AGENCY ❑ FEDERAL AGENCY <br /> O / V / /f/ if ! !`/a ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> NAME STATE ZIP CODE SITE PHONE M,WITH AREA CODE <br /> f G� CA <br /> TYPE OF BUSINESS: EPA ID s <br /> 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN <br /> RESERVATION or M o1 TANK'S <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,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 M WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME `� CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS N ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> /v! j ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M,WIT "REA CODE <br /> v QHS C� s� �j�C_ <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME _ CARE OF ADDRESS INFORMATION <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 PHONE M,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. ❑ II. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY S JURISDICTION k AGENCY N FACILITY ID M M of TANKS at SITE <br /> m I I 1 —1 1 1 = LL F_T7 Ll Lo 16 Fm <br /> CURRENT LOCAL Aq&NCY FACILITY ID N� APPROVED BY NAME PHONE R WITH AREA CODE <br /> V <br /> PERMIT NUMBER l y PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE�DE CENSUS TRACTM _ SUPERVISOR-DISTRICT RICT CODE BUSINESS lPLAN FILED NO ❑ DATE FILED <br /> CHECK M, PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: r/ <br /> 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORM A(3-2-68) <br /> �1 <br />