Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> � ' i <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION .�� XL <br /> �� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ��'--^"-'" <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE z <br /> 10 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACI ITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> / N <br /> ADDRESS NARESTCROSS STREET ✓Sar to imus ❑ PARTNERSHIP ❑ STATE AGENCY <br /> T ❑ c ORATION <br /> El IDL LACE# E) EEOER -ACENc <br /> OD / DIVIOUAI ❑ COUNTY AGENCY W <br /> CITY NAME STATE ZIP CODE E PHONE A.WITH AREA CODE W <br /> LO CA gSZ� 2[)q 3341-3030 <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROR ✓Box it INDIAN EPA ID p #of TANK's <br /> ❑ 1 GASSTATION ❑ 3 FARM OTHER TRUSTTVATION LANDS Or ❑ <br /> 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 /> / r3Ja 20�133�/-363 fly ✓l_ <br /> NIGHTS'. NAME(LAST, ST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> tip, <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ME 19S S <br /> MAILING or STREET ADDRESS ✓Box to intlicate Cl 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 & ADDRESS — (MUST BE COMPLETED) <br /> NAME I CARE OF AO RESS INFORMATION <br /> �aa� <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl ❑ STATE-AGENCY <br /> ❑ PORATION 11 LOCAL AGENCY 11 FEDERALAGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH ARE CODE <br /> 200_33' 30.30 <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. ❑ 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 a JURISDICTION» AGENCY R FACILITY ID# R of TANKS at SITE <br /> EE = = lololll.5kAolo <br /> CURRENT LOCAL AGENCY FACILITY ID If APP7CODERIECEIPT <br /> PHONE N WITH AREA CODE <br /> 'PERMIT NUMBER PERMIT APPROVAL DATE N DATE <br /> LOCATION CODE CENSUSTRACTM SUPERVISOR-DISTRICT CODELED DATE FILED <br /> 7 NO <br /> CHECK# C/ PERMIT AAMMODUNT IS L./ SURCHARGE AMOUNT RECEIPT# 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 /> FORMA(3-2-88) <br /> lie DATA PROCESSING COPY <br />