Laserfiche WebLink
STATE OF <br />FORM `A': <br />SITE <br />. t <br />�O F1•' <br />CALIFORNIA WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PROGRAM ftm <br />FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br />COMPLETE THIS FORM FOR EACH ACILITY/SITE "4111FII <br />MARK ONLY ❑ t NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANE TLY CLOSED SITE <br />ONE ITEM El INTERIM PERMIT El AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE GJ <br />I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />FACILITY/SITE NAME <br />13 <br />01L <br />A -c ' L Co <br />CARE OF ADDRESS INFORMATION <br />NEAREST CROSSJTREET <br />J7? / W& <br />] <br />indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />ORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />ADDRESS <br />3003 n , I D <br />a, <br />APPROVED BY NAME PHONE # WITH AREA CODE <br />V <br />O <br />I �/V- <br />INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME :5—pGG//O _ / ��� <br />ZIP CODE <br />g.��zod <br />STATE <br />ZIP ODE <br />SUPERVISOR -DISTRICT CODE <br />SITE PHONE #, WITH AREA CODE <br />DATE FILED <br />CHECK # <br />PERMIT AMOUNT <br />CA <br />FEE CODE <br />RECEIPT # <br />TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR <br />❑4 CESSOR <br />✓Box if INDIAN <br />EPA ID # <br />of TANK'S <br />1 GAS STATION ❑3 FARM <br />5 OTHER <br />RESERVATION or <br />TRUST LANDS ❑ <br />TAT THIS SITE <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIR <br />PHONE # WITH AREA CODE <br />cvc <br />( <br />209— —3z <br />� A&Y <br />ZD — 3Zq Ir <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) J <br />j PHONE # WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />A -c ' L Co <br />Z.. <br />MAILING or STREET ADDRESS. <br />to indicate 11 PARTNERSHIP 1:1 STATE -AGENCY <br />APPROVED BY NAME PHONE # WITH AREA CODE <br />CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />O <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />STATE <br />C>g- <br />ZIP CODE <br />g.��zod <br />PHONE #, WITH AREA CODE <br />III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />A -c ' L Co <br />Z.. <br />MAILING or STREET ADDRESS S w,ox <br />to indicate ElPARTNERSHIP ❑ STATE -AGENCY <br />APPROVED BY NAME PHONE # WITH AREA CODE <br />CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />Jk_❑ <br />INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME1 V <br />STATS _ <br />ZIP CODE PHONE #, WITH AREA CODE <br />IV. LEGAL NOTIFICATION AND BILLING ADDRESS le-* 9 734 'Z.e 7 <br />CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. ❑ III. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />APPLICANT'S NAME (PRINTED & SIGNATURE) DATE <br />LOCAL AGENCY USE ONLY <br />COUNTY # <br />JURISDICTION # <br />AGENCY # <br />FACILITY ID # # of TANKS at SITE <br />�3 q ® � <br />CURRENT LOCAL AGENCY FACILITY ID # <br />APPROVED BY NAME PHONE # WITH AREA CODE <br />PERMIT NUMBER <br />PERMIT APPROVAL DATE <br />PERMIT EXPIRATION DATE <br />LOCATION CODE <br />CENSUS TRACT # <br />SUPERVISOR -DISTRICT CODE <br />BUSINESS PLAN FILED <br />YES ❑ NO ❑ <br />DATE FILED <br />CHECK # <br />PERMIT AMOUNT <br />SURCHARGE AMOUNT <br />FEE CODE <br />RECEIPT # <br />BY: <br />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. <br />FORMA:(3- 1 2-88) <br />DATA PROCESSING COPY A; <br />7 <br />