Laserfiche WebLink
• -. ... <br /> �OF•. <br /> STATE OF CALIFORN WATER RESOURCES CONTRBOARD 'SSP`"" "r"� <br /> FORM `A': wm <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Y _ ', �� <br /> COMPLETE THIS FORM FOR EACH FACILIMSITE <br /> FMARK ONLY Q, 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE G' <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> vem # g3- 2oc,32 -- <br /> ADDRESS NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ' ` I El CORPORATION 11LOCAL-AGENCY ElFEDERAL-AGENCY <br /> Y E ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> rt CA Q520l(ZQcM52_--57S4-i <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK's ^.� <br /> 129 1 GAS STATION [:] 3 FARM ❑5 OTHER TRUSTYLANDS or ElW <br /> 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 /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> EmarW -rom S21 .0$?10 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> TH <br /> MAILING or STREET ADDRESS ✓�x to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> L7,CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> ,58 '1" I *3 Hl ❑ COUNTY-AGENCY <br /> CITY NAME STATE I ZIP CODE PHONE If,WITH AREA CODE <br /> `9145(g(112 LAN <br /> III. TANK OWNER INFORMATION &ADDRESS (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓$bx to indicate El PARTNERSHIP ElSTATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Om 1 0Jer ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Q_592,5to qz - d <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. ❑: 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# C,� #of TANKS at SITE <br /> lo <br /> E <br /> E[�] I I I j I ! O / FOFn to <br /> CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE#WITH AREA CODE <br /> V <br /> PERMIT NUMBER PERMIT PRO AL DATE P RMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-D ST CT CODE BUSINESS PLAN FILED DATE FILED <br /> IC) <br /> � 2 3,� l YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> 7� <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 /> �j FORM A(3-2-88) 0 0 <br /> DATA PROCESSING COPY <br />