COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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I STATE OF CALIFORNO WATER RESOURCESCONTRBOARD i FORMW: : UNDERGROUND STORAGE TANK PROGRAM !, SITE 4gFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE c9`'FO?�'P MARK ONLY F—] I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANE�NTIYr CLOSED SITE ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 10 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) FACILITY/SITS NAME CARE OF ADDRESS jFqRMATION ^, AIIA ADDRESS NARES CRO STRE T ✓ to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Ci ��111 W��'' VVV��w"`""""' ❑ INDIVIDUAL ❑ COUNTY-AUNTY-AGENCY CITY NANLE! ° STATE ZIP O IjSITE PHINE#,WITH AREA COD C e: WTYPEOFUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # If of TANK's S STATION 3 FARM 5 OTHER RESERVATION or AT THIS SITE ❑ ❑ TRUST LANDS ❑ Q //A EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) a ONE#WITH AREA C DE DAYS: N LAST,FIRST) PHO WITH AREA CODE f-7 p r A NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS:,fV (LAST,FIRST) PHONE#PVITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME ✓ -A .yr—� CARE A INFORMATION MAIL�jior. TBFJ AD S� ✓ tPORA IO ❑ PARTNERSHIP ❑ STATE-AGENCY S S �RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY ME STATE ZIP E 3 q,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING qr$TREET ADORES ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAPE 1 1 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. 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 PEENCOUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE 10101 / 1 -TLFITI � CUNT f.00AL A ENCY FACILITY ID# APP ED Y N E PHONE#WITH AREA CODE PERMIT NUMBER PERMI APP O ATE PERMIT EXPIRATION DATE LOCATIONN CODE CENSUS TRA�Xy SUPERPRE -DISTRICT CODE BUSINESS PLAN FILED DATE VILE l.� �. r�/ YES ❑ NO l� PERMIT AMOUNT SDRC A OUNT FEE CODE RECEIPT# 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 ONLY FORMA(3-2-88) J DATA PROCESSING COPY