COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

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gf,P` pF f STATE OF CALIFORNO WATER RESOURCES CONT&OARD � suaarc,p 'yF ar. as FORM 'A'-. UNDERGROUND STORAGE TANK PROGRAM a w SITE /SITE, INFORMATION and/or PERMITAPPLICATION COMPLETE THIS FORM FOR EACY FACILITY/SITE MARK `OUFpa �° ONLY 1 NEW PERMIT ®3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ®7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Awl vha ADDRESS NEAREST CROSS STREET ✓Boz to uwom ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ COIfMTlON ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ MMOUAL ❑ COUNTY-AGENCY CITY NAME STATEZ CODE SITE PHONE#,WITH AREA CODE CA 7067� TYPE OF BUSINESS: ❑2 DISTRIBUTOR ®4 PROCESSOR ✓Box H INDIAN EPA ID# RESERVATION or #of TA 't 1 STATION 3 F 5 OTHER TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) Y CONTACT PES (SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) - NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CIN NAME STATE ZIP CODE PHONE#,WITH AREA CODE Ill® TANK OWNER INFORMATION ) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE ® LEGAL NOTIFICATION CH ONE(1) II TING I A SHOULD USED FOR G NOTIFICATION AND BILLING: I. ❑ II. ❑ 111.❑ 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 L COUNTY# JURISDICTION# AGE CY# FACILITY ID #of TANKS at SITE CURRENT LOCAL AGENCY FACILfTY ID# APPROVED BY NAME PHONE#WITH AREA CODE NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS FILED DATE FILED YES NO �EIPT#ECHECK# PERMIT T SURCHARGE : FORM UST BE ACCOWANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM IBI APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FOR A(3-2-88)