Laserfiche WebLink
a r* a r. — ra+r+>rB-T- <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE `+�,. P iQ <br /> MARK ONLY ❑ i NEW PERMIT 3 RENEWAL PERMIT EKsCHANGE OF INFORMATION 7 PERMANENTLY CLO D SITE N <br /> ONE ITEM Z INTERIM PERMIT # AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) Ai <br /> FACILITY/SITE AME CARE OF ADDRESS INFORMATION <br /> ADDRESS �> NEAREST CROSS STREET ✓Bw mfoIoOr D PWTNSEIIIP ❑ STATE- <br /> AGENCY <br /> 3 ❑ CO MnON ❑ U0 AGEWY ❑ FEDERAL AGENCY <br /> DUAL ❑ CDUNTY-ASDLCY <br /> CITY NAME ^�� STATE ZIP CODE ITE PION #,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑y DISTRIBUTOR ❑A PROCESSOR ✓Box if INDIAN EPA ID # lzi <br /> 1 GAS STATIONFARM ❑ 5 OTHER RESERVATION or ❑ #of TANK'A <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> a3 —ab <br /> NIGHTS: NAW�hn Am <br /> (LAST,ROT) <br /> n HONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INF MATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to inoicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & AINPRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Sox to iwicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRES <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. 1�1 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID It #of TANKS at SITE <br /> 00 If-17 <br /> OURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATI N CODE CENSUS TRACT* SUPERVISOR-0ISTRICT CODE BUSINESS PUN FILED DATE FILED 3 :A �— [:] —?O <br /> x YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> NV <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST"`OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNI PSS THIS IS A CHANGE OF SITE INFORMATION ONLY. \ <br /> FORMA(3-288, <br /> �' DATA PROCESSING COPY <br />