Laserfiche WebLink
u Off., <br /> 5" <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD I � { <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM ® �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> f9 LIf ORN�P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PER <br /> ENTLY CLOSED SITE <br /> ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> EFACILITYISITE NAME CARE OF ADDRESS INFORMATION <br /> Avic/A vice <br /> L NEAREST CROSS STREET ✓CW0Rrae ❑ PwRLOATTHISSFTE (!�) <br /> FEDERAL <br /> STAERAAG <br /> to NM-tti l Cl INDMOIU110N ❑ OROEML-AGENCY <br /> ❑ INOMWAI ❑ <br /> STATE ZIP CODE SITE PHONA CODETo �1c7� cAs� Lo =�9�/EPA ID M /,NESS. ❑ 2 DIS7111BUTOR ❑4 ESSOR ✓Box if INDIAN _ vRESERVATIONor ❑ <br /> 1 GAS STATION ❑3 FARM 5 OTHER TRUST LANDS <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 /> J /v6,bte �ftNUSti �20`I 5; !l A/01)1`''— <br /> NIGHTS: NAME(LAST.F ST) PHONE 4 WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> 1 r tI <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME / CARE OFADDRESSINFORMATION <br /> Uvv` G�tie' J <br /> MAILING or STREEF ADDRESS <br /> I/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 33 CAI � i� " V ❑ RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> I/t/ t Y1 ISI INDIVIDUAL ❑ COUNTY-AGENCY <br /> Cltt NAME A� l —STATE ZIP COQE� PHONE#,WITH AREA CODE <br /> CIA- <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ff ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> PS ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> IV. LEGAL NOTIFICATION A D BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ IL 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 M AGENCY R FACILITY ID R R of TANKS at SITE <br /> EU 101611 11TEYE 10101010 <br /> CURRENT LOCAL AGENCY FACISITY 10 N 0 I LLODEBUSINESS <br /> PHONE V WITH AREA CODE <br /> AAl PERMIT NUMBPERMIT APPROVAL DATEIT EXPIRATION DATE <br /> 2LOCATION ODE CENWS TRACTNSUPERVISOR-DSPLAN FILED DATE FILED <br /> D2 Qd YES ❑ NO <br /> CHECK E PERMIT MOU uuNT SURCHARGE AMRECEIPT R BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TALK(PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY! <br /> FORM A(3-2-BB) /( <br />