Laserfiche WebLink
0 STATE OF CALIFORNI WATER RESOURCES CONTR ARD fy �K T"F <br /> FORM `A': .� <br /> UNDERGROUND STORAGE TANK PROGRAM =`gyio <br /> m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION w o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �40FORNNP <br /> MARK ONLY 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I-a <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE r <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> alld <br /> ADDRESS /�¢/� �� ) /� NNE�ApR�E�STCROSS STREET ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 106 W 6� !1 01[i ❑ INDIVIDUAL El ION ❑ COUNTY-AGENCY <br /> AGENCY F DERAL GEN <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> 157b h_ CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ ❑ TRUSRESET LANDS ATION or ❑ /�/ to #of HIS SITE [� <br /> 1 GASSTATION 3 FARM 5 OTHER AT THIS SITE l <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) P ONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> I � Z S A <br /> NIGHTS: NAME(LAST,FIRST) P ONE#WITH AREA CODE NIGHf NAME(LAST,FIRST) PHOrjE#WITH AREA CODE <br /> � A RCIA <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF DRESSINFORMATION <br /> u S A A <br /> MAILINsi.or STF?�,ET ADDRES07 ✓pelf to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY 3E US STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <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: I. II. ❑ 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 /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> EI I 1 D 10 1 / 1 l®T I A <br /> CUR ��AGEN�FACILITY ID# APPROVED BY NAME, PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE ��j{�/iC/— 3 P RMIT EXPIRATION DATE <br /> lur <br /> LOCATION CODE CENSUS TRACT# SUPE VISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 0`) v v ` YES ❑ NO (�(_if-- 3 <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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />