Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMf�� <br /> 'A': _ �` <br /> UNDERGROUND STORAGE TANK PROGRAM 0� o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE — <br /> MARK ONLY `rNEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q <br /> 10 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> sit') .16Xi6/uIw Llwr,6y U Ba <br /> ❑ PAATNEPHSTATE-AGENCf <br /> NEAREST CROSS STREx NADDRESS FEDEMLAGEN <br /> LY <br /> INDIVIDUALCOUNTY AGENCY <br /> G STATE ZIP CODE S TE PHONE# WITH AREA CODE co <br /> CITY NAME <br /> j 2Rc`� CA clNs37<�- 205 83S -U � <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK's <br /> � L� RESERVATION or ❑ Nd i AT THIS SITE r <br /> ❑ 1 GAS STATION F-1 3 FARM LsY""� TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST PHONE p WITH AREA CODE <br /> NIGHTS. NAME(LAST,FIRS - PHONE N WITH AREA CODE NIGHT NAME(I T,FIR ) PHONE 4 WITH AREA CODE <br /> e e �3(�- S�f3S� <br /> II. PROPERTY OWNER INFORMATIO & ADDRESS - (MUST BE COMA' E ED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bax Io intlicale D PARTNERSHIP D STATEAGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intlicale D PARTNERSHIP D STATE AGENCY <br /> D CORPORATION Cl LOCAL-AGENCY D 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. If. ❑ 111. ❑ <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 /> 7 <br /> :319 10161011 <br /> CURRENT LOCAL AGENCY <br /> FIACILITY I # APPROVED BY NAME PHONE M WITH AREA CODE <br /> c_J /wV �� <br /> PERMIT NUMBER PERMIT APPROVAL DAATTEE/ PERMIT EXPIRATION DATE <br /> �X <br /> LOCATION CODE CENSUS TRACT# SUP RVISOR-DISTRI CODE BUSINESS PLAN FILED DATE FILED ['p' <br /> , 03 <br /> 7 YES 0 NO 120 _O 0 <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 INFORMATION ONLY. <br /> SFORM A(3-2-SS) <br /> DATA PROCESSING COPY <br />