COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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7,1771177, 77.7 ."T.9wry TATE OF CALIFORNO WATER RESOURCES CONTROOARD �-- EK S �?EP•¢uxiK" rN 4 •• F FORM `A': UNDERGROUND STORAGE TANK PROGRAM Y Abo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE CA cli3ORW MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY 8Q ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY APPROVED BY NAME PHONE #WITH AREA CODE ❑ INDIVIDUAL Cl COUNTY -AGENCY ADDRESS STATE NEAREST CROSS STREET ✓ Boz to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY LOCATION CODE © CENSUS TRACT # p SUPERVISOR -DISTRICT CODE ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY BUSINESS PLAN FILED YES ❑ NO ❑ DATE FILED CHECK # ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME FEE CODE STATEZIP CODE BY: SITE PHONE #, WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR F-14 PROCESSOR ✓ Box if INDIAN EPA ID # # of TANK's ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER RESERVATION or TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE If WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE If WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY CURRENT L?jrrG 5FACILITYID# / ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY APPROVED BY NAME PHONE #WITH AREA CODE ❑ INDIVIDUAL Cl COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME r CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY CURRENT L?jrrG 5FACILITYID# / ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY APPROVED BY NAME PHONE #WITH AREA CODE ❑ 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. ❑ III. ❑ 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 # mEl AGENCY # I I I FACILITY ID # I F� I IE # of TANKS at SITE 1 1 161 CURRENT L?jrrG 5FACILITYID# / APPROVED BY NAME PHONE #WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE © CENSUS TRACT # p SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED YES ❑ NO ❑ DATE FILED 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 ON9 FORMA (3-2-88) 0 DATA PROCESSING COPY 0 CF) Cts jbbN