COMPLIANCE INFO_1988-2002 - Laserfiche WebLink

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-......��.,.-,...-..•.._.,...x�m..,..,....,.,.-Rr4.;-'.r. ..-+.s..+•.�+r=-.,•,.x� w,_a�rr.•.m��•-.-ara.e+rrcim�*.'n*�w.�;"'"..�,."®"""'.f44pb.�,°""_="'`qR�'•'+v `w"sswv'an:'� M NATE OF CALIFORNS WATER RESOURCES CONTR16BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE ,!'5 ,.. •EuniK�'••�F 1 Y O C'q 'FORWP. MARK ONLY ✓ IEW PERMIT ❑ 3 RENEWAL PERMIT i CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE O) 1 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION N1 CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY MAILING or STREET ADDRESS✓/ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY n Q ADDRESS ❑ FEDERAL -AGENCY ZIP CODE NEAREST CROSS STREET✓ oxtoindicate ElPART RSHIP ElSTATE-AGENCY CITY NAME STATE ZIP CODE -{� CORPORATION ElLOCAL-AGENCY [3FEDERAL-AGENCYS1� PERMIT EXPIRATION DATE I I —S72> ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE CENSUS TRACT # SITE PHONE At, WITH AREA CODE F—val0h DATE FILED 0 CA YES [_]NO TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓ Box if INDIAN EPA ID # # of TANK's ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER RESERVATION or TRUST LANDS El ATTHISSITE ODM EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PH E # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE ' e IQu b etj— 3 NIGHTS: NAME (LAST, FIRST) kl r PH E # WITH AREA CODE NIGHTS: NAME (LAST, IRST) - PHONE Al WITH AREA CODE - 77 a— II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME PGICi�I CARE OF ADDRESS INFORMATION N1 e MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY MAILING or STREET ADDRESS✓/ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY IBJ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ZIP CODE ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE Sa PERMIT EXPIRATION DATE I I —S72> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION N1 FACILITY ID # MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY , I g- r /> Lo � ❑ 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. ❑ it. [K III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. LOCAL A LA 'SNAME(PRINT G TUBE) DATE -7 �j�j _7_GS_O 1S sGF CY usF ONLY COUNTY # JURISDICTION # AGENCY #// FACILITY ID # # of TANKS at SITE ® EIV , I g- r /> Lo � CURRENT LOCAL AGENCY FACILITY!LIP # APPROVED BY NAME PHONE # WITH AREA CODE ArPERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT # SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED DATE FILED 0 �3, YES [_]NO e —4 CHECK # PERMIT AMOUNT SURCHARGE AMOUNT E C FEODE RECEIPT # I BY: ij ( I 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. jwA` J' FORMA (3-2-88) DATA PROCESSING COPY � �'