COMPLIANCE INFO_1985-2005 - Laserfiche WebLink

Home Browse Search

, OF STATE OF CALIFORNIP WATER RESOURCES CONTROROARD .... FORM 'A': UNDERGROUND STORAGE TANK PROGRAMrte , fto SITE�C FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C LI COMPETE THS FORM FOR EACH FACII ITY/SITE 0 MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT «, CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 1:1 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION III ADDRESS- (MUST BE COMPLETED) FACILITY/SITE ME gg CARE OF ADDRESS INFORMATION ADDRESS I NEAREST CROSS STREET V Ba to 1*0 Q PARTNERSHIP 0 STATE-AGM 0 CORPORATION 11 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA TYPE OF BUSINESS: 2 DISTRIB6TOR V Box if INDIAN EPA ID# #of TANKs E] I GAS STATION 3 FARM RESERVATION or AT THIS SITE TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS V Box to indicate 11 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 171 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS V Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE IV.- LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. El II. [:] Ill. 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) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# If of TANKS at SITE u F-d o I I I q I "-\ CURRENT LOCAL AGENCY FACILITY 10 APPROVED 0 NAME PHONE 0 WITH AREA CODE L LS fS I I PERMIT NUMBER I PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT 0 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED li /"/,u CURR C E0 NLIN TLOC IT NUI [PERAT13YER LOCATION CODE YES NO 2_6 "7 bl�= I QJ_ CHECKC 0 RECEIPT 0 BY- HECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE \�JTHIS FORM MUST BE ACCOMPANIED BY AT LEAWR MORE TANK PERmrr FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. ORM A(3-2-88)