Laserfiche WebLink
STATE OF CALIFORNIP WATER RESOURCES CONTRBOARD <br /> FORM `A°. <br /> UNDERGROUND STORAGE TANK PROGRAM m <br /> �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °4�'FoR 'pP <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT; ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE t <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) 10 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> villaqe, arc *,3133 <br /> f <br /> N <br /> ADDRESS N R�ST CROSS STREET to ncte ❑ PARTNERSHIP ❑ STATEAGENCY <br /> Mo <br /> LKCORPORATION ❑ LOCAL-AGENCY El FEDERAL-AGENCY <br /> V} mils 14o /t 14 7/v <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATEF ZIP CODE SI E PHONE#,WITH AREA CODE <br /> G CA _5-AQ <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # A� n .p #of TANK's <br /> ATION <br /> 1 GAS STATION ❑ 3FARM ❑ 5OTHER TRUSTVLANDSor ❑ /I� �,< l� <br /> JAT THIS SITE 5 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> spa cL ro v Ca®qIt 7?­5:55d, Ro p r}1des C415 5`Z/—a`f�7 <br /> NIGHTS: NA4E(LAST,FIRSTT PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 13a e- <br /> ll. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME J CARE OF ADDRESS INFORMATION <br /> I-IfxC o m rd rn (ac�ccc f S (?0, <br /> MAILING or STREET ADDRESSx to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Flo <br /> ..✓)� S t CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> �J / alle ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMELo e fift e ter STATE ZIPS.ODE PHONE#,WITCODE <br /> LlC <br /> I11. TANK OWNER INFORMATION &ADDRESS,—(MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> ARC© e u.wL P/1 Co, <br /> MAILING of STREET ADDRESS ox to indicate ElPARTNERSHIP ElSTATE-AGENCY <br /> J^+ ly CORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> V/ <br /> V t ? ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME ����© STATE ZIP COD PHONE#,WITH AREA CODE <br /> S /L.' /�/J f57!- <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS I <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 111.tl <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 /> FPERMITNUMBER <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> Q ® / 4a / LOOQ �" <br /> AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS S N❑FILED NO DATE FILEDPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION Olj Y <br /> FORM A(3-2-88) \J <br /> DATA PROCESSING COPY <br /> - <br />