Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> �yt`au„t�''tf <br /> w. A <br /> FORM 'A': <br /> . <br /> UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 FOR LOSED SITE IJ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE - <br /> N <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N <br /> 00 <br /> FACILITY/SITE NAMECARE OF ADDRESS INFORMATION <br /> VZLrj <br /> 'Lc2 5 f Lp S <br /> ADDRESS NEAREST CROSS STREET ✓ birdiM 0 PARTNERSHIP ❑ STATE AGENCY <br /> /� �T� ''/A CORPORATION 0 LOCAL AGENCY 0 FEDERAL-AGENCY <br /> 1 R! t/ W ElINOMDUAL 0 COUNTY-AGEND <br /> CITY NAME // STATE IP COD SITE PHONE#,WITH AREA CODE <br /> S G tl fJ� CA JT D <br /> TYPE OF BUSINESS'. ❑ p DISTRIBUTOR ❑4 PROCESSOR ✓RESBox if INDIAN EPA ID # M of TANICF <br /> ❑ I GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUSTYlANDIs Or ❑ 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 /> e Cao9 6 _ iG <br /> NIGHTS: N ME(LAST,F ST) PH NE N WITH AREA CODE NIGHTS'. NAME(LAST, RST) HONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S a <br /> MAILING or STREET ADDRESS ✓Gox to intlicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME ^7 CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Sax tointlicate 0 PARTNERSHIP 0 STATE-AGENCY j <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY1 <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE f.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. x <br /> 11. ❑ 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 N JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> ml = = 100a3 (0a 101oo / <br /> CURRENT CA AOENCY FACILITY ION LCODESUSiNESS <br /> PHONE N WITH AREA CODE <br /> wlto R � <br /> PERMIT NUMBER PERMIT APPROVAL DATET EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT a SUPE117( -DPLAN❑FILED DA FILED <br /> ^A//O(1YES NO <br /> CHECK# PERMITAMOUNT SUR CHARGE ARECEIPT# 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(3-2-8&) <br /> �r DATA PROCESSING COPY a,)( <br />