Laserfiche WebLink
y OF T... I <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL/OARD �P fiUNFKA' �A <br /> FORM `A': 'a <br /> UNDERGROUND STORAGE TANK PROGRAM fm <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Cq�FORN P <br /> MARK ONLY 1-11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 LOSED SITE I"� <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1 N ADDRESS COMPLETED)MUST BE <br /> 1. FACILITY/SITE INFORMATION & SS <br /> ( tV <br /> FACILITY/SITE NAME MwX n CARE OF ADDRESS INFORMATION <br /> I� <br /> +7 �L i <br /> ADDRESS NEAREST CROSS STREET ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ����/I /,,/ Q� ❑ CORPORATION ❑ LOCA- ENCY ❑ FEDERAL-AGENCY <br /> I/(p® j 1101/ 4 ❑ INDIVIDUAL N1Y-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE <br /> CA Srfij <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4 P OCESSOR ESE x if INDIAN <br /> EPA ID It #of TANK'S <br /> 1 GAS STATION 3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FLRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAM LAST,FIRST PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIR5K) <br /> / PHONE#WITH AREA CO f <br /> III CC L.( C! <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME 6 CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> (J ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE _ ZIP�>� PHONE#,WITH AREA CODE <br /> C-IrT /ice v <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> ' F ✓� lei. Gvve /qU f <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ElSTATE-AGENCY <br /> �,G. <br /> ` aIJ� �G� ❑ 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. ❑ 1111pn <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# FA-z-1 <br /> CIIL_ITY ID# ##of TTAjNKS atSITE <br /> E�l I I 1 -1 El L:l I (/ la <br /> z 317171 Lo <br /> V V / <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> &(3 �sr <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIO�CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLA N FILED DATE FILED <br /> c <br /> ((�,t�1t YES � NO � —7Y, <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# B j <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 /> FORM A(3-2-88) l <br /> DATA PROCESSING COPY <br />