Laserfiche WebLink
STATE OF CALIFORNIA( WATER RESOURCES CONTROL BOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1 0 <br /> COMPLETE THIS FORM FOR EACH FA /SITE <br /> FMARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F"a <br /> ONE ITEM ❑2 INTERIM PERMIT ❑q AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 0000 <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) -4 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION A <br /> ADDRESS y q c Ale? <br /> NEAREST CROSS STREET ✓B Wirbcak El PARTNERSHIP ❑ STATEAGENCY <br /> -7 / C i r P 4-7 / ❑ CGRPOR TION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> ❑ Nom UAL ❑ COUNTY.AGBICY <br /> CITY NAME STATE ZIP CODE SITE PHONE*,WITH AREA CODE <br /> L C14 CA 95"y yo <br /> TYPE OF BUSINESS: ❑ 2 UIOR ❑ d PROCESSOR I ✓Box if INDIAN EPA ID a <br /> ❑ 1 GASSTATION E!f3 FARM ❑ 5OTHER TRUSTVATION LANDS or ❑ 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 /> B#/P� <br /> 79 <br /> NIGHTS: NAME(LAST.FIRST( Zt/vo-lE*WITH AREA CODE NIGHTS'. NAME(LAST.FIRST( PHONE*WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> r <br /> MAILING or STREET ADDRESS Box to ale C3 PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ ORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> NDIVIDUAL ❑ 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 /> �Liove �, <br /> MAILING or STREET ADDRESS ✓Box - icate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ PORATION ❑ LOCM-AGENCY ❑ FEDERAL-AGENCY <br /> NDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. Fvrit. ❑ 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 R JURISDICTION N AGENCY TI FACILITY ID R X of TANKS BI SITE <br /> [afl i t s I I I I / L <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE <br /> Tr L <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 9 IP 3 a3 a YES ❑ NO ❑ 6-/3— <br /> CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT* BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFOR4ONLYY. <br /> ORM A(3-2-88) <br /> DATA PROCESSING COPY <br />