Laserfiche WebLink
Y a 5 y <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> yt'J ryf <br /> Y <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION �S7 PERMANENTLY CLOSED SITE F"+ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) A <br /> FACILITY/SIeeTE NAME — .ARF nF ADDRESS INFORMAT—KI A <br /> d� co -� (-.C, f�Qf5aNS <br /> ADDRESS NEAREST LZROSS STREET ✓ bndKNe ❑ PARTNERSHIP ❑ STATE AGDO <br /> Z Cht'ro ee GGN� Gook d(1aC ❑ IN°D D�°N O cuu1xrrAGEICY AG91D ❑ FEDERAL aGENp <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> GaoL� CA 52 O 2v4-369-/ S <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Be.if INDIAN EPA ID N Not TANK'N <br /> tz I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTVATION LANDS or ❑ L�/V/\ 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 /> /SdNS 36 <br /> NIGHTS: NAME(I-AST, WITH ST,FIRST) AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> (SUNS 2Oq 33 y 0(05 Gf A/ <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> c K.C. Sa,S cp & l<c- ws-OW?. <br /> MAILING or STREET ADDRESS ✓Box to Indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> u+�� CORPORATION IDLOCAL-AGENCY 11FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE ONE M.WITH AREA CODE <br /> Gac� � 4 45Zyo Zoq 33y-otos <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SANE As A-d dun7e►� <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP E3STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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 it. ❑ 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 N JURISDICTION N AGENCY N FACILITY IDN N o1 TANKS at SITE <br /> ® = = 121011= Ooz/ <br /> CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE N WITH AREA CODE <br /> 41 T25 <br /> PERMIT NUMBER PERMIT APPill Nk D TE PERMIT EXPIRATION DATE <br /> LOCATION CODE CEINISUSTRI SUPERVISOR-DISTRICT CODE BUSINESS PLAN NO <br /> N❑FILED 1 j <br /> CHECK N<_ PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONI UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> `� DATA PROCESSING COPY <br />