Laserfiche WebLink
STALE OF CALIFORNI.0 WATER RESOURCES CONTROAOARD 15 � r".f <br /> Y0 pA <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION a <br /> COMPLETE THIS FORM FOA,-EACH CILITY/STYE "&iF;. r`° <br /> MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT EE�5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SI <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> Imo_ <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME'/ r CARE.OF ADDRESS INFOR TION <br /> a <br /> ADDRESS ' I NEAREST CROSS STREET v/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY F-•a <br /> �• *yI` I G�p IAV <br /> 1:1 CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCYCo <br /> 11 Y 5;-%DIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZI CODE SITE PHONE At,WITH AREA CODE <br /> d CA CIS J <br /> TYPE OF USINESS: F-12 DISTRIBUTOR ❑ 4 PROCESSOR */Box if INDIAN EPA ID #RESE #of TANK'r <br /> 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTVATION LANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAY NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> �'f� asftA L <br /> NIGHTS: NAME(LAST RS PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> I S <br /> .II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME rCARE OF ADDRESS INFORMATION <br /> LL, z--> L. eA <br /> MAILING or STREET ADDRESS ✓Box to indicate 11PARTNERSHIP ElSTATE-AGENCY <br /> ''ww C; CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME 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. ❑ Il. ls�r III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICA 'S NA PRIN &SIGNATU DATE <br /> LOCAL AGENCY USE ONLY <br /> �I <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> E= L -T-1 E <br /> o <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TR T# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 23,90 a C0 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(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> _IW DATA PROCESSING COPY <br />