Laserfiche WebLink
IA r°F <br /> SOURCES CONTR�BOARD /e�" URI <br /> STATE OF CALIFORWATER RE <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM _ �0 <br /> w <br /> SITE /77 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °"k,F°R"" <br /> F <br /> ARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> NE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> B E� <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ,4A)k vin DO <br /> ADDRESS NEAREST CROSS STREET ✓BgWmfficale Cl PARTNERSHIP ❑ STATE-AGENCY w <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> c��/L/ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODESI E PHONE#,WITH AREA CODE <br /> CA 33C -239-2 W& <br /> TYPE of BUS SS: F—] 2 DISTRIBUTOR ❑4 PROCESSOR */Box if INDIAN EPA ID #RESER #of TANK's <br /> AS STATION [:] 3 FARM ❑5 OTHER TRUST VLANDS ATION°f ❑ 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 If WITH AREA CODE <br /> 6alkl� "V /ky 235-9 '7'� 10 Cie r-?o9 1 -:r/ -�f <br /> NIGHTS: NAME(LAST, ST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> (?"boom <br /> MAILING or STREET ADDRESS r ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CJ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> V /d 2- [&-+NDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME � CARE OF ADDRESS INFORMATION <br /> f/ <br /> � f <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: I. 11. ❑ III. ❑ <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 /> FPERN <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 1_3__M Ia / IF�_T__j I c t--�31 <br /> AGENCY FACILITY I APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAFL <br /> YES NOPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> 0 DATA PROCESSING COPY <br />