Laserfiche WebLink
STATE OF CALIFORNIIX WATER RESOURCES CONTROL BOARD 5` <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM u �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ® ; <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5C7HANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE x <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CN <br /> FACILITY/SITE NAME /^/^ CARE OF ADDRESS INFORMATION <br /> W- Q <br /> ADDRESS NEAR CRO TREET ✓Bmblw4ab 0 PABRIElE111P 0 STATE AGENCY <br /> ❑ CC/�POPATIDN 0 LOG4L-AGENCY ❑ FEDEML A030 <br /> G ❑ INDNIDM ❑ WUN AGENY <br /> CITY NAME C STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> J CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> ❑ 7 GAS STATION ❑ 3 FARM ❑ S OTHER pgUSTVLANOS TION or ❑ AT TANKs <br /> THIS SITE 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#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST( PHONE N WITH AREA CODE NIGHTS: NAME(I-AST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ 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 ✓Boz to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <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. ❑ II. ❑ 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 /> COUNTYIN JURISDICTION M AGENCY# FACILITY ID R R of TANKS at SITE <br /> M�l I I I zi= i <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 23 /� Z YES [—] [—] I/NO 7,& <br /> CHECK# PERMIT AMOUNT SURCHARGEAMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1),QR MORE TANK PERMIT FORM IBI APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION0 <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY of <br /> 1 <br />