COMPLIANCE INFO_1987-2001 - Laserfiche WebLink

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nrr,� it--�$,- zT"a'h: � .. :.. CT4'V�r•-rscr�-r�•-_,..v<._a.�.. ----�F STATE OF CALIFORN10 WATER RESOURCES+ CONTROL'80ARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o G COMPLETE THIS FORM FOR EACH FACILITY/SITE OF R, MARK ONLY �1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT E 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ' W CARE OF ADDRESS INFORMATION CITY NAME STATE IPC DE HONE WITH AREA CODE ❑ FEDERAL -AGENCY CITY NAME ADDRESS ZIP CODEP NE #, ITH AREA CO44e)'DDEEJ,�'� NEAREST CROSS STREET ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY CORPORATION ❑ LOCAL -AGENCY Cl FEDERAL -AGENCY SUPERVI OR -DISTRICT CODE I� �` / v� DATEJFILED O � CHECK # NDIVIDUAL ❑ COUNTY -AGENCY Cl NAME FEE CODE STATE ZIP CODE BY: SITE PHONE #, WITH AREA CODE CA 9'�Z03 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓ Box if INDIAN EPA ID #RESE F�iylGAS STATION ❑ 3 FARM 5 OTHER TRUSTY ANI DS ON or a) V I TAT f TANK's THIS SITE 3 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (AST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) HONE #�7WITH AREA CODE /� (5AGSD(J �//�(] GL % Z ^ Irl mLo (� Czol)) 2-- (0 17 - NIGHTS: NAME (AST, F ST) PHONE # WITH AREA CODE NIGHTS: NAME (LAS , FIRST) HONE # WITH AREA CODE _zm)339-C411 A <_S cw 20q (0 II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) �60T) �j NAAz6o CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ' W ✓ to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE IPC DE HONE WITH AREA CODE ❑ FEDERAL -AGENCY CITY NAME STATE ZIP CODEP III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAMAR6 CARE OF ADDRESS INFORMATION AGENCY # Er I I MAILING or STRE ADDRESS ✓fix to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY 5811 Q" CORPORATION ❑ LOCAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY ❑ FEDERAL -AGENCY CITY NAME STATE ZIP CODEP NE #, ITH AREA CO44e)'DDEEJ,�'� LOCATION CODE CENSUS TRACT # p9�0 SUPERVI OR -DISTRICT CODE I� �` / v� IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK Obd4Q BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. R II. v5r III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. TE APPLICANT' NAME (PRINT D & SIGNATOR DA a C,/ LOCAL AGENCY USE ONLY COUNTY # EE JURISDICTION # I 1 11 AGENCY # Er I I FACILITY ID # # of TANKS at SITE 10101/1_9�_F [01010T17 CURRENT LOCAL AGENCY FACILITY ID # APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT # p9�0 SUPERVI OR -DISTRICT CODE BUSINESS PLAN FILED YES EJ NO DATEJFILED O � 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 ISA CHANGE OF SITE INFORMATION ONLY. ORM A (3-2-88) OITA PROCESSING COPY ` 0