Laserfiche WebLink
STATE OF CALIFORNI.._,, WATER RESOURCES CONTRA.._ BOARD <br /> t <br /> FORM-`A°. <br /> UNDERGROUND STORAGE TANK PROGRAM =`� � m <br /> SITE FACILITY/SITE, INFORMATION and or PERMIT APPLICATION �� <br /> ,., <br /> 16 <br /> COMPLETETHIS FORM FOR EA i'I F CitiTY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT E] El3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PE NTLY CLOSED SITE <br /> ONE ITEM <br /> 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE __4 <br /> J <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE CO PLETED) L" <br /> FACILITY/SITE NAME n�M v CARE O "ADDRESS INFORMATION <br /> ADDRESS NEAREE T CROSS STREET ✓Baz hale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �! RPORATION ❑ 10Ck-AGENCY ❑ FEDERAL-AGENCY <br /> D ./� INDNIDU ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE SITE PHONE ITH AREA CODE <br /> YLA cL23-37v/ V IL <br /> TYPE OF BUSINESS: ❑ 2 DES UTOR ❑ 4 PROCESSOR ✓Box h INDIAN EPA 10 # <br /> RESERVATION or R of TANK s <br /> ❑ 1 GASSTATION FARM ❑ 5 OTHER TRUSTLANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EME GENCY CONTACT PERSON(SECONDARY) <br /> DAYS: N (LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME{LAST,FIRST) PHONE#WITH AREA CODE <br /> v 601 r c1 L_ It/-- <br /> NIGHTS: NAME(LAST,FIRS ) PHONE#WITH AREA CODE NIGHTS NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE O ADDRESS INFORMATION <br /> 5 i��c wS <br /> MAILING or STREET ADDRESS ✓ ox to indicate 11PARTNE RSHiP ElSTATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY El FEDERAL-AGENCY <br /> ElINDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BECOMPLETED) <br /> NAME CARED11 ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓ ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. EV II. ❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> F <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 1A - 1 -1 0 1 1 14 o Tyl I I I _L <br /> AGENCY FAC1L1f ID APPROVED NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER OCL/]' PERMIT.APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSU TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> �/ v YES ❑ NO [—] 6 r <br /> — { <br /> CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE COVE RECEIPT N BY: 4/p <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($),UNLESS THIS IS A_ CHANGE Of SITE INFORMATION ONL <br /> FORM A(3-2-88) <br /> DATA PROCESSING OPY • <br />