COMPLIANCE INFO_FILE 1 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNI0 WATER RESOURCES CONTROSIARD FORMW: : UNDERGROUND STORAGE TANK PROGRAM i SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r l G COMPLETE THIS FORM FOR EACH FACILITY/,SITE c"OF.R" P MARK ONLY t 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 T31%; 1 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME 11i�1. CARE OF ADDRESS INFORMATION V 5 OF DRESS INFOR^TION 6 I' LOCAL-AGENCY!FEDERAL-AGENCY AD SS i ❑ INDIVIDUAL ❑ COUNTY -AGENCY ✓ Box to indicate ❑ PARTNERSHIP ElCORPORATION ❑ LOCAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY NEAREST CROSS STREET✓ Box to indicate El PARTNERSHIP EI STATE -AGENCY C3CORPORATION ElLOCAL-AGENCY FEDERAL -AGENCY /� lS � D PERMIT EXPIRATION DATE STATE CA ZIP CODE I q-,61-ctolo ❑ INDIVIDUAL ❑ COUNTY -AGENCY Y NAME CITALA BUSINESS PLAN FILED YES NOPERMIT STATE Z1C57n SITE PHONE k, WITH CODE /Fy`q.'Y,� SURCHARGE AMOUNT FEE CODE 4 C)' �ofT 4• TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR Box if INDIAN EPA ID # # of TANK's f GAS STATION [:]3 FARM 5 OTHER RESE❑ TRUST LANDS or ❑ M 2t 002 30 ATTHIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIT) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) KJ PHONE # WITH AREA CODE LbS ?.9J q 44 -"0 4 NIGHTS: NAME LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRS PHONE # WITH AREA CODE -0207- blwf II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NIAVE Nfi 11i�1. I L TIES L 1.) t CA D 5 OF DRESS INFOR^TION 6 I' LOCAL-AGENCY!FEDERAL-AGENCY M LING or STREET ADDRESS O 7 ❑ INDIVIDUAL ❑ COUNTY -AGENCY ✓ Box to indicate ❑ PARTNERSHIP ElCORPORATION ❑ LOCAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY TATE-AGENCY FEDERAL -AGENCY CITY NAME sftQ PHONE It. WITH AREA CODEuq PERMIT EXPIRATION DATE STATE CA ZIP CODE I q-,61-ctolo PHONE #, WITH AREA CODE -a-l- III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAMRE N(�) OF DDRESS INFORMATION 1 �N 0 VS Ft eub s or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP �❑�S TATE-AGENCY 1:1CORPORATION El �1, G� 31Q LOCAL-AGENCY!FEDERAL-AGENCY �J S ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE A ZIP CODE PHONE It. WITH AREA CODEuq IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 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) DATE LOCAL AGENCY USE ONLY THIS FORM MUST BE ACCOMPANIED BY AT LEAST (t) OR MORE TANK PERMIT FORM `B' APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. ORM A (3-2-88) 0 DATA PROCESSING COPY S JURISDICTION # AGENCY # FACILITY ID # # of TANKS at SITE mil 8zl 2g AGENCY FACILITY ID # A NAME PHONE #WITH AREA CODE EPERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CENSSUSTRACT# SUPERVIS R -DISTRICT CODE BUSINESS PLAN FILED YES NOPERMIT DATE FILED AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT # BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST (t) OR MORE TANK PERMIT FORM `B' APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. ORM A (3-2-88) 0 DATA PROCESSING COPY S