COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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OSTATE OF CALIFOR WA` IiR RESOURCES CONTR OARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION n , COMPLETE THIS FORM FOR EACH.RACILITY/SITE OF URI�f' Y � p C,a tlFo RN.�P IMARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE G I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION ✓ Box to indicate ❑ PARTNERSHIP Cl STATE -AGENCY CURRENT LOCAL AGENCY FACILITY ID # ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY APPROVED BY NAME PHONE # WITH AREA CODE ❑ INDIVIDUAL ❑ COUNTY -AGENCY ADDRESS STATE NEAREST CROSS STREET ✓ Boz to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY L CENSUS TRACT # ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY 1121:2. 06 VA 1% th -all CHECK # ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE SITE PHONE #, WITH AREA CODE N_ CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓ Box if INDIAN EPA ID # ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER RESERVATION or TRUST LANDS ElAT # of TANK's 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 II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP Cl STATE -AGENCY CURRENT LOCAL AGENCY FACILITY ID # ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY APPROVED BY NAME PHONE # WITH AREA CODE ❑ 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 CURRENT LOCAL AGENCY FACILITY ID # ❑ 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. ❑ if. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. J APPLICANT'S NAME (PRINTED & SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY # Y� JURISDICTION # AGENCY # FACILITY ID # # of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID # APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT # SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED YES ❑ NO ❑ DATE FI O .3 CHECK # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT # B 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. FORMA (3-2-88) DATA PROCESSING COPY • .�