Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM a <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> I:C] <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT K5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE z <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) le <br /> FACILITY/SITE NAME CARE OF ADDRE FORMATION <br /> S ��.mP, <br /> ADDRESS NEAREST CflOSS STREET ✓Bow to ir�arale PARTNERSHIP ❑ STATEAGENCY N <br /> 6 F Gf�(9 7 W 'Sl osu5 1-1GOVRKIIAA`COGNTYAGENCI <br /> ION El LOCALAGENCY❑ ❑ FEDEMLAGENCI tSI <br /> CITY NAME S7�Gl�-7oN STATCA ZIP ���O� SITE PHONE#,WTJIAREAiODE <br /> TYPED USINESS: ❑2OSTRIBUTOR ❑4PROCESSOR -/Box if INDIAN EPA IDN AVVryry <br /> If TANK's /f <br /> 1GAS STATION ❑ 3FARM ❑ 5OTHER TRUSTYLANDS ION or El of <br /> THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) . PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> IAl \ g -O <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST, RST) PHONE N WITH AREA CODE <br /> Z - -07 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> v A e Sam. <br /> MAILINGSTR ET ADDRESS I/Box to indicate PARTNERSHIP ❑ STATE-AGENCY <br /> fly` { �. ♦♦�yT T��,�pp (�/ ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> V / C�7/7 / YxC. ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> -7- <-rc�e <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME r CARE OF ADDRESS INFORMATION <br /> £ u hwfkmSa,w.e <br /> MAILING o,STRE ADDRESS /� tl �� / ✓Box to indicate ARTNERSMIP ❑ STATE-AGENCY <br /> I G ^" " 11 INDIVIDUACORPORATL ❑ OUNTY AGENCY LOCALp FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> s�oc lr-ia <br /> col q.rW(o x/63-asg8 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 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 N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> o � 3 61 ado s <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> 6 <br /> PERMIT NUMBER PE MIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> (J 10 VES NO ,Z 'OQ <br /> ff <br /> CHECK N <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N SY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERNIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> "' DATA PROCESSING COPY ��� w\� <br />