Laserfiche WebLink
RECEIVED <br /> JUL 06 2020 <br /> STATE OF CALIFORNIP Wi%""" <br /> K3QNTR�OARD <br /> FORM AA': DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION `o <br /> its/ to <br /> _ f COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> [— <br /> MARK ONLY ❑ 1 NEVWRMIT ❑3 RENEWAL PERMIT E:]5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> F-� <br /> I.FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) c� <br /> FACILITY/ME NAME C CARE OF ADDRESS INFORMATION 1 JI <br /> :ADDRESS NEAREST CROSS STREET ✓8aq.male 13VNIINER49P ElSIAIEAGENCf <br /> ❑ CMWTION ❑ lax rGlrxr ❑ cEOEau AGFhcr <br /> -_ __ ❑ W(XiIIWAI ❑ COOTYAGEhCY <br /> CITY NAMEI STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS. 2 DISIF DR /PROCESSOR ✓Boz J INDIAN EPA ID A <br /> RESERVATION or of TANK's <br /> ❑ 1 GAS STATION ❑3 FARM ❑5 OTHER ITRUSTLANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERS (PRIMARY) EMERGENCY CONTACT PERSON(SECONDAR ) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PH NEN ITH AREA CODE <br /> NIGHTS NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS NAME(LAST,FIRST) 1 10NE WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATIO &ADDRESS — (MUST BE COP TE ) <br /> NAME CARE OF ADDRES INFO ATION <br /> MAILING or STREET ADDRESS %/80. <br /> 80■to fn0'c ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORA ❑ LOCAL-AGENCY ❑ FEOERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGF-NCY _ <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMAI ION <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ COHPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> _❑ INDIVIDUAL ❑ COUNTY-AGENCY _ <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH EGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ III.❑ <br /> THIS FORM I fAS BEEN COMPLETED UNDE71 PENALTY Or PERJURY,AND 70 IE BEST OF MY KNOWLEDGE,IS TRUE AND CORREC7 <br /> APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY M FACILITY`v N N of TANKS of SITE <br /> CURRENTLOCAL AGENCY F LITY 10 N I ADP VED BY NAME PHONE#WITH AREA CODE <br /> PE MIT NUMBER - PERMIT APPROVAL DATE PERMIT EXPIRATION DAT <br /> lOC ION CODE CENSUS TRACT N SU_RR R•DIBTRICT CODE BUSINESS PUN FILED DATE FIL D <br /> — -- --- YES NO < = -1 , <br /> CHECK N PER MjIIIMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 1 BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEA$T(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. C" <br /> FORMA(3.2.88) \ \ <br /> I <br /> DATA PROCESSING COPY <br /> �- <br />