Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> ea <br /> C,--/ <br /> - COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 215 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY SITE CLOSURE �Q <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FAC TY/SITE NAME I^ CARE OFADDRESS INFORMATION <br /> f /1 <br /> ADDR I NEAREST CROSS STREET ✓SratrxCip@ 0 PABTNERR9P D STATE AGENY <br /> D CORPORATON D LOCAL-AGENCY 0 FEDERAL-AGMEN <br /> 0 INONIOUAL 0 COUNTY-AGENCY <br /> CITY NAMEJJ �� STATE ZIP CODE SITE PHO NE#,WITH AREA CODE <br /> (lam CA <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOfl ❑4 PflOCESSOR ✓BOx if INDIAN EPA ID q <br /> RESERVATION or If of TANKS <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5OTHER TRUSTLANDS ❑ ATTHISSFTE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS. NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE R WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box toineicate Cl PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> D INDIVIDUAL D 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. ❑ 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# JURISDICTION# AGENCY# FACILITY ID M #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> � I I � <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR•DISTRICT CODE BUSINESS PLAN FILED DATE FI DD C/ <br /> ` , �I �' �/ 'zv YES [j NO 11 ✓ ` O <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <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 INFORMATIONQNLY. <br /> FORM A(3-2-88) C. <br /> (/T1 �d DATA PROCESSING COPY <br /> SAL <br />