Laserfiche WebLink
v..q�laaT`T7.�'�^^�m,s•"'V Alp <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARDS"°° ,'rF <br /> FORM `A'. �1 <br /> UNDERGROUND STORAGE TANK PROGRAM I <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> LECOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATON ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> ifl <br /> 20 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ' i^ <br /> ADDRESS F NEAREST CROSS STREET ✓fl scale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> (} �� RR0 ION Cl LOCAL-AGENCY ElFEDERAL-AGENCY <br /> r I r'o N_ V-✓fl ❑ INDIVIDUAL ❑ COUNTY-AGENCY `Ah. <br /> CITY NAM^, , I ,, STATE ZIP CODE SITE PHE#,WITH AREA CODE to <br /> Y'`'l CM <br /> CCL, <br /> CA ,� 3 � O -cossq <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID a #of TANK's <br /> ❑ 1 GAS STATION 1:13 FARM THER TRUST�LANDS ATION Dr ❑ AT THI5 SITE ' <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE q WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> 13U Rill Q ►�wf�ea T <br /> NIGHTSNAME(LAST,FIRS PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> f kt-0 e I L r u, XAC ll,�o C-- <br /> MAILING <br /> 1MAILING or STREET ADDRESS �✓Da�tta�indicate ElPARTNERSHIP ❑ STATE-AGENCY <br /> I , fir. f L3'CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> _ I �76 7 ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME f STATE ZIP CODE PHONE#,WITH AREA CODE <br /> +�fZa 2t <br /> III, TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Lj <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <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. lKli. ❑ 111. 71 <br /> THIS FORM HAS BEEN COMPUTED UNDEP PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT, <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS et SITE <br /> [HO EIU I 9 a 173-1 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> LgTHISFORM <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO ❑ <br /> PERMIT AMOUNT SURCHARGE MOUNT FEE CODE RECEIPT# BY: <br /> BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B`APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> DATA PROCESSING COPY <br />