Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> { <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM o Z <br /> SITE 1 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ® 7 PERMANENTLY CLOSED SITE w <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 5� O <br /> 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> tD <br /> FACRITY/SITE NAME CARE OF ADDRESSINFORMATION <br /> ars � <br /> o, s a Nr N SwearrAi eN <br /> ADDRESS NEAREST CROSS VTREET ✓&abiidi 0 PARTN IP 0 STATE AGENCY <br /> 3 S (r W �(6da-z/1��] Ad Cl x a O COUNTY sENa.0134 AGENGf ❑ mEw 4cEN <br /> CITY NAME STATE �� ODE STE PHONE N,WITH AREA; <br /> oc +� CA �SzbS 207 —0/6© <br /> TYPE OF BUSINESS: ®2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> RESERVATION or If of TANICa <br /> ❑ I GAS STATION ❑ 3 FARM ❑ 50THER TRUST LANDS ❑ /V&JWE AT THIS SITE f <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 /> Min (014 t, Qe'NNlS z.—ow) Su�etrr/ ten. e 2 �— <br /> NIGHTS: NAME(LAST, RST) PHONE N WITH AREA CODE NIGHTS: NAME(LA T,FIRS PHONE it WITH AREA CODE <br /> Cart P,vN(5 9 - 2 /b0 57a)220PJ✓ Barl, 4 <br /> II. PROPERTY dWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESSI <br /> P i`SoNS O� co irwgr'n✓iGt' N FORMATcIONION r.J <br /> MAIUNGcL BLEE/T�AD/D'R�ESS c ✓ ox to indicale Cl PARTNERS 0 STATE-AGENCY <br /> / ,� / .-J INDIVIDUAL ION 0 LOCAL-AGENCY 0 COUNTY AGENCY ElFEDERAL-AGENCY <br /> CITY NAM le STATE ZIC7( 1 (75:2 2 P CODE NEN,WITH AREA CODE I <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> 66 <br /> NAME I CARE OF R7FORM NS O� COI C�71/lfii � /% CcJ ! �,ti <br /> MAILING or STREET ADDRESS (, ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /T (��P{f/�CO� RPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY <br /> 5, J �� LI INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE - PHONE p,WITH AREA CODE <br /> � S520a 2 "Y78 -�8 <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. 0 it. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION R AGENCY a FACILITY ID R X of TANKS at SITE <br /> ® = = 10 " 1,2 2-1 <br /> d 10 1 C) <br /> CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMITAPPROt DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR- ISTRIRIICT ODE BUSINESS PLAN FILED DATE FIL (� / <br /> Z3,(!©O OC ( YES NO // X00 E-41 <br /> CHECK* PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: <br /> THIS FORM MUST BE ACCOMPANIED P"AT LEA' 1 OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATIO Y. . <br /> FORMA(3-2-88) <br /> \ \ DATA-PROCESSING CO?� _./ <br />