COMPLIANCE INFO_1995-2002 - Laserfiche WebLink

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9, $."i.r tf ?. 1 [# -• Al, 1K i'�` •i': ;.�:..^: d ki FlN� :Ri'u ,S'q �•A3 ' „`i4a; -re.y�T •- :,� /+��$x� ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY '•;ifL �/ /' J� A � J. STATE OF CALIFORNIA WATER RESOURCES CONTROL OARD E l t.. P y. .�:iK�•.�F W. •A FORM `A': UNDERGROUND STORAGE TANK PROGRAM W `� SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� C% COMPLETE THIS FORM FOR EACH FACILITY/SITE C-LIFORto 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 I Q I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILI ITE NAMb CARE OF ADDRESS INFORMATION CARE 7F ADDRESS INFORMATION ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY MAILI G or STREET ADDRESS �/ /' J� A ❑ STATE -AGENCY ❑ FEDERAL -AGENCY ADDRESS %� /%� A / ? /. ' NE ST C OSS STREET ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ❑ CORPORATION ❑ LOCAL -AGENCY EDERAL-A NCY `V ( [V + (/l/.� STATE ❑ INDIVIDUAL ❑ COUNTY -AGENCY (,c.• CITY NAME // STATE ZIP CODE PTEPH NE #, WITH AREA CODE DE CENSUSTRAC # CA �SZ�P7S DATE FILED11 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓ Box if INDIAN EPA ID # llS # of TANK's GSTATION ❑ 3 FARM ❑ 5 OTHER RESERVATION or TRUST LANDS ❑ FEE CODE RECEIPT # AT THIS SITE E Or� EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE # WITHAREACODEDAYS: (LAST, FIRST) PHONE #/WITH AREA CODE RA NIGHTS: NAME (LAST, IRST) PHONE It WITH AREA CODE NIGHTS: ME (LAST, FIRST) PHONW WITH AREA CODE S' A VIA II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME lit CARE OF ADDRESS INFORMATION CARE OF/ADDRESS INFORMATION ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY MAILI G or STREET ADDRESS �/ /' J� ✓ Boox/x to indicate Cl PARTNERSHIP El CORPORATION ❑ LOCAL -AGENCY ❑ STATE -AGENCY ❑ FEDERAL -AGENCY xi L +lo ❑ INDIVIDUAL ❑ COUNTY -AGENCY PHONE #, WITH AREA CODE CITY NAME PERMIT APPROVAL DATE STATE ZIP CODE ONE # ITH AREA CODE Z PHa 3 -1 III. TANK OWNER 14FORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY FSTTID ❑ 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. ❑ if. Ili. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANTS NAME (PRINTED & SIGNATURE) DATE LOCAL AGENCY USE ONLY # JURISDICTION # AGENCY # FACILITY ID # # of TANKS at SITE FSTTID I o dill vn AL AGENCY FACILITY ID # 10 q APPROVED B ILEO PHONE A WITH AREA CODE [PERMITR PERMIT APPROVAL DATE PERMIT EXPIRATION DATE DE CENSUSTRAC # SUPERV OR -DIS RICT CODE BUSINESS PLAN FILED DATE FILED11 �3_�YES ❑NO� llS it PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT # BY. THIS FORM MUST BE ACCOMPANIED BY AT LEAST(I OR MORE TANK PERMIT FORM `B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. eFORM A (3 2 88) DATA PROCESSING COPY