Laserfiche WebLink
FL <br /> STATE OF CALIFORNYIe WATER RESOURCES CONTOreBOARD °' r` <br /> A <br /> FORM A : UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Z <br /> 10 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> F /SITE NAME OTMTAT <br /> INFORMATION <br /> TREEF ^ ✓Bw NnkraR ❑ PAAiNEFSNIP ❑ SiPTEAGENO' N <br /> ADDRESS D I �nI �Ou_ ❑ DUALCORPORATION Cl IOU AGENCY <br /> F AS <br /> (/ rµy..� ❑ PATI T,�,�tH❑ii LOAN(AASGNCY 6qQ� .{fix <br /> CITY N�'�% ZIP COOE I(/J 74 F �NE#WITIHAR CO�O p <br /> W A/PL 1 V� CA <br /> TYPE OF BUSINESS: Box ff INDIAN EPA ID N <br /> ❑2 DISTRIBUTOR ❑4 PROCESSOR RESERVATION Or ❑ M of TANKY <br /> GAS STATION ❑3 FARM E] 5 OTHER TRUST LANDS AT THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMER ENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST FIRST) PHONE#WITH AREA DE DAYS: NAM (IAST.FIRST) ONE N WITH AREA CODE <br /> o g <br /> NI TS'. AME(IA T,FIRST) P NE#WITH AREA OF NIGHTS: N ME(LAST,FIRST) -0 <br /> GIJE N WITH AREA CODE <br /> r z+ a <br /> II. PROP RTY OWN R INFORMATION & ADDRESS - (MUST BE.COMPLETED) <br /> NA CARE Of RESS INFORMATION <br /> Gor ET AD SS • ✓ xto iodi"te ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY E -AGENCY <br /> x /O& ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY ME STATE ZIP CODE HONE N, ITH AREA CODE <br /> Cfb 7 Zoo �l- <br /> Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF AqDFESS INFORMATION <br /> PA D <br /> MAILING rS REET ADDRES§ ✓Box to ird,cate ❑ PARTNERSHIP D STATE-AGENCY <br /> O CORPORATION ❑ LOCAL-AGENCY GER -AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY N E STATE A� ZIP CODE PHPON ITH AREA CODE <br /> /+ J <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. 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# AGENCY# FACILITY ID# N of TANKS at SITE <br /> 6 1 7 5 7 rolo 10 3 <br /> CURRENT LOCAL AGENCY FACILITY ID# APP VE BY NA/�I� PHONE x WITH AREA CODE <br /> PE IT NUMBER PERMIT PP V L DATE PERMIT EXPIRATION DATE <br /> LLO�LATIONCODIE CENSUS TRACT• SUPER ISOR-DISTRICT CODE BUSINESS PLAN FILED F E <br /> YES E] NO ❑PERMIT AMOUNT SURCHAR EAM LINT 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 /> \�RM A(3-2-SB) \ (' <br /> v ./ DATA PROCESSING COPY <br />