Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM W� m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �o o <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE C'l to oN <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT AMENDED PERMIT 6 TEMPORARY SITE CLOSURE � <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) ~ <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 1.t7cz- ertoo Food * ewe I <br /> ADDRESS L ', 1 �//�� NEARES`T,CROSS/STREET ✓Boz to indicate PARTNERSHIP ❑ STATE-AGENCY <br /> 11 303 a }- tel/Q I (7 Rol, �GG6 / ❑ INDIVIDUAL ❑ COUNTY <br /> AGENCY El LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAMESTATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> S'�o C.,K40n CA 'a o Cao �t <br /> TYPE OF USINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID# <br /> RESERVATION or /�� N Q #of TANK'a 3 <br /> 1 GAS STATION ❑3 FARM ❑5 OTHER TRUST LANDS ❑ /r D/{ C. 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 /> v4 m m 10 L& fr, i a oq z/&6-,5916 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S (ao� Sgl-by�'3 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Musa- -e Rose, Abu k h d o- ; r <br /> MAILING or STREET ADDRESS ✓Box to indicate VPARTNERSHIP ❑ STATE-AGENCY <br /> o�S 1 a l u1 tri , ❑ CORPORATION EILOCAL-AGENCY ElFEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> m o dies -o C2--'53 55 1 0oJ5 5 A -5370 <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ,S 4Q IF CL. 9 D no peel tu 0 inner <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. X <br /> if. ❑ Ill.❑ <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 /> 10101 / 17DiZ [0101 :0::Pl <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> ,VaZer <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 0t / ;13, 9'O YES NO / <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(8), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> >' FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />