Laserfiche WebLink
STATE OF CALIFORNIA . WATER RESOURCES CONTRb1BOARD 4-0: <br /> �•�^iva�x�'*'YA <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C' COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT F—] 3 RENEWALPERMIT 5 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) I C) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> N <br /> ADDRESS NEAREST CROSSSTREET B.to mtlkate ❑ PAATNEAGHIP ❑ STATE-AGENCY <br /> //J PORATION C1 LOCAL 13 FEDERAL AGENCY 00 <br /> 3 `Q II ` �� u�� NIOUAL ❑ COUNIY AGENCY �iVyVyVy.Fi/ <br /> CITY NAME STATEZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA 5 aoq <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 P OCESSOR ✓Bax it IN EPA ID p <br /> ❑ I GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS ATION d ❑ �'< #of TAN / <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) I, <br /> DAYS: NAME(LAST,FIRST( PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> Sm of riat4ne- <br /> NIGHTS. NAME ILA FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Scan 009 L03-- /day <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> N o r m cwt- 14' i w S <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 3 ❑ PORATION 11LOCAL-AGENCY [IFEDERAL-AGENCY <br /> OIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE p WITH AREA CODE <br /> Ienm )Prn C(4 as Cao9 759-3' /00 <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME \ CARE OF ADDRESS INFORMATION <br /> q Cvn S o <br /> MAILING or STREET ADDRESS ✓Bo oinaicate L] PARTNERSHIP ElSTATE-AGENCY <br /> x ❑ RPORATION CILOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 3 N• DIVIDUAL ❑ COUNTY AGENCY <br /> Cltt NAME / STAJE _ ZIP C D }1aONE v# TH AREA CODE <br /> OD�tq3 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> C,/�T C n( 'TaO <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. X11. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# If of TANKS at SITE <br /> ® E= /Ta571 1 ,010101 / 1 <br /> CURRENT LOCAL GENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE Q. <br /> LOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED NO GAT FILED,g ,(� Q <br /> D <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# B <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 /> 11ORM A(3-2-SS) �1 <br /> DATA PROCESSING COPY •.-`J <br />