COMPLIANCE INFO_1987-1998 - Laserfiche WebLink

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.Yw'v�.`�'w.a'v^FBow�l9�lr•4 r. �A14�"1 ASTATE OF CALIF R WATER RESOURCES CONT�L BOARD FORM `A': :. gym UNDERGROUND STORAGE TANK PROGRAM �0 SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE �""FOR=" MARK ONLY❑ EW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE Q I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME t s l Coop CARE OF ADDRESS INFORMATION FACILITY ID # hip b t c t ❑ STATE -AGENCY ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ADDRESS CORPORATION ElLOCAL-AGENCY NEAREST CROSS STREET ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY (1 ❑ INDIVIDUAL ❑ COUNTY -AGENCY 1 �� El CORPORATION ❑ LOCAL -AGENCY [_1FEDERAL-AGENCY 77 STATEZIP / _ ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME C eco r CL STATE ZIP CODE I SITE PHONE #, WITH AREA CODE BUSINESS PLAN FILED DATE FILED CA[f5'207Cao , 7 7 8-- TYPE OF USIN SS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓ Box it INDIAN RESERVATION or/ EPA ID # ,( 0-v # of TANK'S d/ GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS El! �' ` � 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 NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE sct m It" vq3+-ao 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME t s l Coop CARE OF ADDRESS INFORMATION FACILITY ID # MAILING or STREET ADDRESS ✓ Wlto indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ��/ o CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY r V JL o a— ❑ INDIVIDUAL ❑ COUNTY -AGENCY CI NAME STATEZIP CODE PHONE #, WITH AREA CODE C° 0 eco r CL C a Ll I c,Af 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION ,,pp /� '' } Q �/'� go %%1 G Q o w G r FACILITY ID # MAILING or STREET ADDRESS v ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY I I I I ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY 16611111c*al Lolo-Fo—W ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I.. II. ❑ Ill. ❑ 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 LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # # of TANKS at SITE [m] I I I I El I I 16611111c*al Lolo-Fo—W CURRENT LOCAL AGENCY FACILITY ID # APPROVED EIV N PHONE # WITH AREA CODE 44,012 4� /E 1 PERMIT NUMBER PERMIT APPROVAL DDA IY �Q PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT #PERVISOR-DI TRICT CODE BUSINESS PLAN FILED DATE FILED , 7 YES [:] NO 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), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. ORM A (3-2-88) —46 DATA PROCESSING COPY ; m.