Laserfiche WebLink
O <br /> STATE OF CALIFORN WATER RESOURCES CONTROBOARD /yoF r <br /> /` ••'•cuner�'••NE <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> �o <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - r <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C'Q(�FORN�P <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PER LOSED SITE 0 <br /> ONE ITEM E]2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION W <br /> ae <br /> ADDRESS QAir NEAREST CROSS STREET ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ,3 [' / /y ElCORPORATION C3LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> J / ck�wWY`. G ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME , STATE U I ZIP CODESJTE PHONE#,WITH AREA CODE <br /> CA J� d ea0 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or #of TANK's <br /> 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CON CT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORWMITION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> k <br /> I <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> I ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME ST E ZIP CODE PHONE#,WITH AREA CODE <br /> f IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NO KATION AND BILLING: I. ❑ II. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST F MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 10 10 1 / 131 16 6 1s' 1 <br /> G _ <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROV§p BY NAVE PHONE#WITH AREA CODE <br /> lhLrD 35 <br /> PERMIT N MBER PERMIT APPROVAL DATE PERMIT 77!�ATE <br /> o1Fo <br /> LOCACENZT � SUP�SOR-DIST�T CODE BUSINESS PL ❑FILED DATE FIL� ❑YES NO % <br /> Y <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNTFEE CODE RECEIPT# BY: <br /> I . <br /> f <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST l OR MORE TANK PERMIT FORM 'S'APPLICATION(S),U, CSS THIS IS A CHANGE OF SITE INFORMATION ONLY. 1 <br /> FORM A(3-2-88)_yq/\ <br /> �f DATA PROCESSING COPY ' <br />