Laserfiche WebLink
STATE OF CALIFORNIAlC' WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE - <br /> MARK ONLY ❑ ) NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOS D SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 - <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) F+ <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> NEAECROSSEET ✓BWmimWe ❑ LOXAGD ❑ STAERGFNDADDRESS — ❑ FARPOAAiION ❑ COUNTYAGN ❑ FEDEIULAGENIX <br /> INDMWAL ❑ NE11, I,;THACITY NAME STACY <br /> ZIP CODE SITE PHONE p,WITH AREA CODE <br /> TYPE OF BUSINESS: ISTROUTOR ❑ 4 PROCESSOR ✓Box i'INDIAN EPA ID a M of TANK'N <br /> ❑ RESERVATION or <br /> ❑ I GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE o / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 12-2a tl u T I7? C-4a dQ 40 s g <br /> NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST B COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET n- ✓Boxt icaI ❑ PARTNERSHIP ❑ STRTE-AGENCY <br /> ❑ FOR ION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> NDIVIDUL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE <br /> C as 7ucL <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> A <br /> MAILING or STREET ADDRESS ✓Bo indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,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 R JURISDICTION R AGENCY# FACILITY ID It #of TANKS at SITE <br /> 3I ol o 1 v / <br /> CURRENT LOCAL AGENCY FACILIT}'14 ,^l APPROVED BY.NAME PHONE N WITH AREA CODE <br /> PERMIT NjCODECENSUS <br /> /'L(/�f (,�`r[�1 'POE/RRMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3 YES NO <br /> CH CKRMIT 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 INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />