Laserfiche WebLink
t <br /> STATE OF CALIFORNIP WATER RESOURCES CONTRO�OARD <br /> FORM `A': 'm <br /> UNDERGROUND STORAGE TANK PROGRAM Eo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° _6, o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE CqI,FORK P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT jjr5 CHANGE OF INFORMATION ❑ 7 PE ENTLY CLOSED SITE 11�' <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> ;D <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) 00 <br /> 00 <br /> FACILITY/SIPIAME CARE OF ADDRESS INFORMATION <br /> 1NA!5.15 &g3 <br /> ADDRESS HL I� W NEAREST CROSS STREET ✓Boz to indicale El PARTNERSHIP I-] STATE-AGENCY <br /> ® / Y ��46�, �� El 1:1 INDIVIDUALION Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHO #,WITH AREA CODE <br /> ,43 CA �153 � ZGU —23�f �rI <br /> TY�OFSINESS: � 2 DISTRIBUTOR ❑4 PROCESSOITRUSTLANDS <br /> ✓Box if INDIAN EPA ID #RESERVATION or #ofTANK's <br /> STATION ❑ 3 FARM ❑ 5 OTHER ❑ AT THIS SITE <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 /> I <br /> —, L(� <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS - ✓Box to indicate El PARTNERSHIP 13STATE-AGENCY <br /> 4��� / Rol ❑ CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> """))) V `/1 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE#,WITH AREA CODE <br /> u nrt� r c G s'2 6 -7 . <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) ti <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 NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ Ii. vIII. ❑ <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# AGENCY# FACILITY ID# #of TANKS at SITE <br /> [01 1' 1 11 El 1-1 1 Q O 9,�] lolo = <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> N `fn <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATI N CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> -?_ �v z1b YES ❑ NO ❑ ?__9_8? <br /> CHECK# PERMIT 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 ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY I <br /> �1 <br />