Laserfiche WebLink
STATE OF CALIFORNM WATER RESOURCES CONTReBOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM = " e z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 02r5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I'a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 3 4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME p� CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET vb+bkale ❑ PAAINEASBIP ❑ STATE AGENCY <br /> /1 / a ') / c '%TION ❑ LocuAGDNCY ❑ EEDwuAGB+a <br /> _ f0 W INDVIDUAL ❑ CDUN,r_AGENa <br /> CITY NAME STATE ZIPLODE-,� v SITE PHgN,ZTH AREA CODE <br /> CA Iljj 55 v l/L/— <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Bard INDIAN EPA ID p <br /> RESERVATION or M ITIS SI <br /> ❑ I GAS STATION ❑ 3 FARM El OTHER TRUST LANDS ❑ THIS SITE I <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECOND RY) <br /> DAYS: NAME(LAS .FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE If WITH AREA C DE <br /> NIGHTS'. NAME(LAST,FIRST) PIKH H AREA CODE NIGHTS: NAME(LAST.FIRST) PA 4 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 5 <br /> MAILING or STREET ADDRESS -/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME SCARE OF ADDRESS INFORMATION <br /> w+T,p � � <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE 11,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. IT I. ❑ Ill. ❑ <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 N JURISDICTION N AGENCY N FACILITY ID If K of TANKS at SITE <br /> [a = = 10101 elll 17171 1010101 / 1 <br /> CURRENT LOCAL AGENCY FACILITY I N APPROVED BY NAME PHONE R WITH AREA CODE <br /> Ra <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT 3 SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED NO <br /> ❑ DATE FILEO—/�_ <br /> liq <br /> CMECKK PERMIT AMOUSURCHARGE AMOUNT ZU JrFEE CODE RECEIPTB(YD`:�� <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-Ei <br /> �Ba/ DATA PROCESSING COPY rj <br />