COMPLIANCE INFO_1986-1994 - Laserfiche WebLink

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STATE OF CALIFOR& WATER RESOURCES CONTR BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION /� / � j COMPLETE THIS FORM FOR EACH FACILITY/SITE .q0l —aF ;;•. 0 .••'euaiK� '•.'f Cq,®OR�P I fr✓ MARK ONLY ❑ NEW PERMIT F]3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION E]7 PERMANENTLY CLOSED SITE ONE ITEM l_1CI ` INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ell I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SIT ME CARE .QF ADDRESS INFORMATION MAILING or STREET ADDRESS CARE OF ADDRESS INFORMATION # of TANKS at SITE ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY `� ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ADDRESS PHONE k, WITH AREA CODE PERMIT EXPIRATION DATE NEAREST CROSS STREET ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY CENSUS TRACT # SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED YES ❑ NO ❑ ❑ CORPORATION 11 LOCAL -AGENCY ElFEDERAL-AGENCY CHECK # c5acra/�,� CSI FEE CODE ❑ INDMDUAL ❑ COUNTY -AGENCY CITY NAME BY: STATE ZIP CODE SITE PHONE #, WITH AREA CODE CA SINESS: ❑ 2 DISTRIBUTOR TY�IGAS,' ❑ 4 PROCESSOR ✓ Box if INDIAN EPA ID # TATION ❑ 3 FARM ❑ 5 OTHER RESERVATION or TRUST LANDS ❑ NK'ts FATTHIS 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 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE .QF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY # of TANKS at SITE ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE k, 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 # of TANKS at SITE ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ 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. ❑ 11. ❑ 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 # ff4l JURISDICTION # AGENCY # FACILITY ID # # of TANKS at SITE LOCAL AGENCY FACILITY ID # APPROVED BY NAME PHONE #WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE OI CENSUS TRACT # 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 ONL FORMA (3-2-88) DATA PROCESSING COPY f' COD L"