Laserfiche WebLink
- 1 <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 'yEP`f p. T" <br /> FORMW: <br /> : e <br /> UNDERGROUND STORAGE TANK PROGRAMA <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION f !gym <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) w <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 5Hr <br /> ADDRESS N AREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> A.CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 62 1 ,) PAC,I r L I— ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> S� CA 5z-COSY( <br /> TYPE Ok BUSINES : ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID g <br /> RESERVATION or #of TANK's <br /> 54 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FAST) PHONE#WITH AREA CODE <br /> 4's- <br /> 11. <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> v -6 �,►_ L <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> _ //�� CORPORATION 11LOCAL-AGENCY ElFEDERAL-AGENCY <br /> 1110 00 1!INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> L_ cr> 1 144SZG (a710- 14 I <br /> I11. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S �V 01L_ COWIPALINf 5 <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> p,�c� CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> iNI.110161 I fill INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE =,EITH AREA CODEGA.. 4S2 (oliv 1414 <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. ITV 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&SIGN AT ) DATE <br /> RILE Ill C_ AL�JL_ i 2-28 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> EE I I � 2 2 <br /> CURR ET LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES [:] NO [_] y L <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST r"OR MORE TANK PERMIT FORM 'B'APPLICATION(S), Ut""S THIS IS A CHANGE OF SITE INFORMATION ONLY.` \ <br /> FORM A(3-2-88) \))) <br /> s1 DATA PROCESSING COPY <br />