Laserfiche WebLink
ATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> IMA': UNDERGROUND STORAGE TANK PROGRAM <br /> (TE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> od <br /> -n� COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY )❑ <br /> 1 N W PERMIT F-] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE <br /> ONE ITEM J F,_ . INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURV . <br /> to <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME ( ARE OF ADDRESS INFORMATION <br /> REST CROSS STREET PREq ❑ STATEAGE� <br /> %DnRESS FONU [I LOCALAGENCY ❑ FEDERAL <br /> AGENCY <br /> N <br /> INDIVIDUAL ❑ CGUNIRAGENGY <br /> STATE 21P CODE SITE PHONE X.WITH AREA CODE <br /> riff NAME <br /> a r. CA 1 <br /> TYPE OF BUSINESS: ❑pp15 IfTOR ❑4P SSOR Box if INDIAN EVA ID — MWTANKI ' <br /> RESERVATION or ,,/ AT THIS SITE <br /> 1 GAS STATION ❑3 FARM OTHEP TRUST LANDS ❑ / Y�� <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> / PHONE X WITH AREA CODE 0 YS: NAME(LAST.FIRST) PHONE X WITH AREA CODE <br /> DAY$ NAME(LAST.FIRST) <br /> .1 _NIGHTS: NAME(LAST.FIRST <br /> PHO M WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE X WITH AREA CODE <br /> jNAerA <br /> PROPERTY OWNER INFORMATION & ADDRESS (MUST BE COMPLETED) <br /> E OF ADDRESS INFORMATION <br /> C or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 'f' ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE CODEHONE X,WITH AREA CODEAME �� <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CPAR DF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Bax to indicate [01 PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZJ CODE PWONE X,WITH AREA CODE <br /> TY NAME rip <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 111•❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> AGENCY X FACILITY ID X X of TANKS at SITE <br /> COUNTY X T�JURISDICTION X <br /> IBJ <br /> rV) F7771 F=- <br /> APPROVED BY NAME PHONE*WITH AREA CODE <br /> R1ENT LOCAL AGENCY FACILITY IDX , <br /> PERMIT EXPIRATION DATE <br /> PERMIT NUMBER RMIT Ap.ROVAL DATE / / `. <br /> //d /F s <br /> BUSINESS PLAN FILED D FED / <br /> TION CODE _CENBI�B TRACT N $UPBt1VISOR-DISTRICT CODE NO ❑ G U y� ,,lf <br /> U, YES 1 <br /> -7j <br /> >�I FEE CODE RECEIPTN <br /> CHECK a PERMIT AMOUNT `SU ClU1ROE AMOUNT <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 ON <br /> FORM A T 2-86) - <br /> FILE COPY ' <br />