Laserfiche WebLink
r <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL ARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANEN.Ii.Y CLOSED SITE yy <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURECTIV <br /> G <br /> 10 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> F2 eV A) q-03y2 ry <br /> ADDRESS 2 / (�,� �\�} NEAREST CROSS STREET ✓B IM-tl ❑ PARINERGNIP ❑ STATE AGENCY <br /> 1 7 Lt � , &L— I�oa6 RPBRATIGN ❑ COUNTY AGENCY ❑ fEGER4L-AGENCY <br /> 0-o a6 INGIVIWAL ❑ COUNTY#GENCY Fj <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> S-7adl or/ CA q6X,946 jV6 ?-- 39, 77 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Bax if INDIAN EPA ID N <br /> RESEGAS STATION ❑3 FARM ❑ 5 OTHER TRUSTMLANDS ATION G ❑ AT THIS SITE <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 /> NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAS IR ) PHONE tt WITH AREA CODE <br /> 1514- S ,&-- <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMEAA// CARE OF ADDRESS INFORMATION <br /> QSCA�I #1 <br /> MAILING or STREET AppRESS ✓Box to <br /> ❑ Cintlicate PARTNERSHIP ElSTATE-AGENCY <br /> ORPORATION LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> G / <br /> 13 INDIVIDUAL11COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE <br /> SNNpl , v&le 9 Ofr.1, I JN,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & A DRESS— (MUST BE COMPLETED) <br /> NAME ems' CARE OF ADDRESS INFORMATION <br /> M I <br /> MAILING or STREET ADDRESS O X 6 3_ ^ ✓B to intlicate EI PARTNERSHIP ❑ STATE-AGENCY <br /> / ORPORATION ElLOCAL-AGENCY0 FEDERAL-AGENCY <br /> 1 1/ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME S7k STATE ZIP E �a PHONE#,WITH AREA CODE <br /> G//&r <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. ❑ I. ❑ III.DK I <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# #of TANKS at SITE <br /> = = = 101611101 ,610110101 ,I_ <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> G/Te v,eo <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE or <br /> t 2— V-f Gtr <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED j <br /> 6?17 Z �'Q Gf 2j00 YES NO `✓ <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> as <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST W OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> L, <br /> DATA PROCESSING COPY <br />