COMPLIANCE INFO_1986-2001 - Laserfiche WebLink

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STATE OF CALIFORNO WATER RESOURCES CONTRRRRRRRBOARDy °"�;"T"� WP. •'Sd FORM `A': 'm UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r �� 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE Cq 0F.Rol MARK ONLY F-11 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I-& ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 00 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CA I" FACILI SITE NAME CARE OF ADDRESS INFORMATION 01019 ✓f CIlJ ADDRESS NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAM . STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA TYPE OF BUSINESS: F__j 2 DISTRIBUTOR F-1 4 PROCESSOR ✓Box if INDIAN EPA ID # If of TANK's RESE❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUSTYLANDS�r ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(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 I NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) 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 III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY j ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE I IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ III.❑ 1 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 i 1 LOCAL AGENCY USE ONLY I COUNTY# JURISDICTION# EAGENCY# I LI- FACILITY ID# 21$ F#of TANKS at SITE i CURT LOCAL AGENC FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE (- tOx / PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA N CODE CENSUS TRACT] SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI/L}ED ' 3. Sl YES NO 7 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UV.ESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) DATA PROCESSING COPY