Laserfiche WebLink
5E'P OFSTATE OF CALIFORNIA WATER RESOURCES CONTRO06ARD <br /> auwsrq �F <br /> UNDERGROUND STORAGE TANK <br /> 4e. SA <br /> T <br /> f <br /> p _ <br /> SITE FACILITY/SITE, I IAPPLICATIONY ® ' A <br /> COMPLETE TIS FORM FOR EACH11 /SITE 61,ORN�P <br /> [�MARK <br /> L El NEW PERMIT ®3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY SED SITE <br /> ONE ITEM 2 INTERIM PERMIT ®4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION -( ) <br /> FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION <br /> S I <br /> ADDRESS NEAREST CROSS STREET ✓Bas b' ' ❑ PARTNEIEM9P ❑ STATE-AGENCY <br /> j� ❑ TI0N ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> -I , ❑ INDMDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> G <br /> TYPE OF BUSINESS: ®2 DISTRIBUTOR ®4 PROCESSOR ✓Box if INDIAN EPA ID# - #of TANK': <br /> 1 GAS STATION 3 FARM ❑ 5 OTHER RESERVATION <br /> or ❑ <br /> AT THIS SITE <br /> EMERGENCY C TACT PE (PRIMARY) EMERGENCY CTACT 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,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION - ( ) <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#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION ® ( ) <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#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATIONILLI <br /> CHECK ONE(t I BOX INDICATING WHICH ABOVEA 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGIENCY# FA/CILITY ID# #of TANKS at SITE <br /> 7-79 <br /> I Li 141olo El <br /> C <br /> URRENT LOCAL A ECYlFACILITY ID# PROVED Y NAME PHONE#WITH AREA CODE <br /> LsS <br /> NUMBER RMIT OVAL DATE PERMIT EXPIRATION DATE <br /> TION CODE USTRACT# SUPERVI R-DI ICT CODE BUSINE FILED DATE FILED <br /> YES NO t— 1K# PERMIIT AMOUNT SURCHARGE AMOUNT CODE RECEIPT# BY: <br /> THIS FORM MUSTACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMITAPPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONI <br /> FORM A(3-2-88) <br />