SITE HISTORY - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN6.) WATER RESOURCES CONTRtVA OARD FORM A: UNDERGROUND STORAGE TANK PROGRAM _ �T SITE FACILITY/SITE, INFORMATION and/or PERMIT;APPLICATION � ;�,, 10 G i COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 00 FACILITY/SITE NAME i; CARE OF ADDRESS INFORMATION [IADDRESS ! NEAREST CROSS STREET ✓Bax Io rd ate ElAMN9SKIP ❑ STATE-MENCY (. I,�D ❑ ITaoRAnoN Eltacu-AGI:NL7' ❑ FEDI�.AGM • NDmlwns. COUNTY-AGENCY CITY NAME i STATE .I' ZIP CODE §ITE PHONE N,WITH AREA CODE f ;.CA TYPE OF BUSINESS: ❑ 2.D3STRIBUTOR ❑ 4 PROCESSOR ✓BOX ii INDIAN EPA ID N RESERVATION or 3 li #of TANK'n F-1 �- TH 1 GAS STATION ❑3 FARM ER TRUST LANDS ❑ 74 i AT THIS 5IlE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS:. NAME(LAST,FIRST) � IY PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE 2C 335-�33a €;i` .SGNLJ} - 3S-£S3�'� NIGHTS: NAME(LAST.FIRST) 1: PHONE It WITH AREA CODE NIGHTS: NAME(LAST, RST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS" (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION tl v MAILING or STREET ADDRESS., - I'✓Box to indicate" ❑ PARTNERSHIP ❑ STATE-AGENCY - s E� L:1_G45APORAT0N ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY T LK INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ''•' ZIP CODE PHONE N,,WITH AREA CODE zoo D�JS�O O 111. TANK OWNER INFORMATION &ADDRESS— (MUST BErCOMPLETED) NAME !I CAAE OF ADDRESS INFORMATION '; V 4 1 ► i' 3' lip . MAILING or STREET ADDRESS _ 'i',✓Box to indicate ❑ PARTNERSHIP CI STATE-AGENCY ' r- ,I 'I {❑❑� C��HgPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY E I 1 GYTNDIVIDUAL ❑ COUNTY-AGENCY CITY NAME i STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS A s CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L 11. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) j DATE LOCAL AGENCY USE ONLY 1 'lia COUNTY# JURISDICTION# AGENCY# r ! FACILITY ID#. #of TANKS at SITE T 7 Ld- 0- J , CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME jPHONE N WITH AREA CODE!" PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE s a,. LOCATION CODE CENSUS TRACT N. SUPERVISOR-DISTRICT CODE - BUSINESS PLAN FILED DATE FILED q i .t: ❑ ( YES NO CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORA)MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMR-FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) ' ! DATA PROCESSING COPY- (