Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROLBARDo"'`' <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m �< 110 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 1 ''r, <EERMIT 3 RENEWAL PERMIT CHA GE OF INFORMATION 7 P NENTLY CLOSED SITE <br /> MARK ONLY ❑ J�'"` ❑ ❑ <br /> ONE ITEM 21NTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE d _ O <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 00 <br /> 4 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> , �� as Sc�,wl1 <br /> ADDRESS NEAREST CROSS STREET ✓BoxlovNiule ❑ PARTNEASHIP ❑ STATE-AGEND <br /> V O DINDIVIDUAL <br /> NOA ° AEc11 EGEHu AGENCY ILo wrvry Gr <br /> CITY NAME STATEZIP CODE SITE PHONE .WITH AREA CODE <br /> CA <br /> C 6 �!_ P �- <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4PROCESSOR ✓Bos it INDIAN EPA ID N <br /> K of <br /> 1:11 GAS STATION El3 FARM ❑ 5 OTHER TRUSTTVAT THIS <br /> SITE <br /> or ❑ �-S <br /> TE L <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) P PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> o Sc� <br /> NIG S. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME �/ SO O✓ OF ADDRESS INFORMATION <br /> Y ARE <br /> bi� <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ElCORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> ( ria Q 0 11INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME —7"&LSTATE ZIP CODE `3 ^� PHONE p,WITH AREA <br /> III. TANK OWNER INFORMATION & ADDRESS — (M ST BE COMPLETED) JJ l 5 <br /> NAME 9/. -- _ ! J & r CARE OF ADDRESS INFORMATION <br /> WAR 4L <br /> MAILING or STREET ADDRESS Be.✓ tointlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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. ❑ If. ❑ 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 M JURISDICTION N AGENCY N FACILITY ID M K of TANKS at SITE <br /> MI = = 1 10 / 6 10- 101 o <br /> CURRENT LOCAL AGENCY FACILITY ID N / APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE /C'PEERRMIMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N� SUPERVISOR-DISTRICT CODE BUSINESS PLAN F'317� YES ❑ILED NG ❑ DATE FILED <br /> CHECKN PERMIT AMOUNT SURCHARGE AMO NT FEE CODE RECEIPTN BYW <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(3-2-88) <br /> ' a � _� 1 DATA PROCESSING COPY <br /> - I \ R� <br />