Laserfiche WebLink
1^ATE OF CAL1 FO R N I WATER RESOURCES CONTROL BOARD <br /> ORM `A': UNDERGROUND STORAGE TANK PROGRAM -o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C'aLIFpF��P <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT wl 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE <br /> 00 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> 17) <br /> FACILITYPe.- <br /> E NAME - 1- 1... CARE OF ADDRESS INFORMATION <br /> R to intlicale EJ PARTNERSHIP ❑ STAiE-AGENCY <br /> ADDRESS NEAREST CROSS STREET ✓ <br /> GORPOR4TION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> - (}l•U[./� INDIVIDUAL ❑ CGUNTY-AGENCY <br /> [/' STATE ZIP CODE SITE PHONE k,WITH AREA CODE <br /> CITY NAME <br /> C cc ' 0� CA Q a . <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ d PROCESSOR ✓Box if INDIAN EPA ID # rAT <br /> TANK's <br /> 5 OTHER RESERVATION or ❑ HIS SITE <br /> ❑ 1 GASSTATION ❑ 3 FARM ❑ TRUSTLANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> C? - ` SCJ <br /> NIGHTS: NAME{LAST.FIRST) <br /> PHONE#WITH AREA CODE NIGHTS, NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> R C, c 207 -1$10 <br /> II. PROPERTY O ER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> �fQ <br /> MAILING or STREET ADDRESS ox to indicate ❑ PARTNERSHIP Q STATE-AGENCY <br /> r��^ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> SO la ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CITY NAME <br /> CI <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NA164E <br /> CARE OF ADDRESS INFORMATION <br /> y <br /> MAILING or STREET ADDRESS ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> h CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> !'1 Ll ��, ���/ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> i✓ - !!�� STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CITY <br /> kaacitAN <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. ❑ 11. 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 P SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 101071 Q <br /> CURRENT LOCAL AGENCY FACILITY ID# <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NU BER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> DATE FILED <br /> Cl �� _31190 YES No <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMfT FORM `B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FARM A(3-2-881 it <br /> DATA PROCESSING COPY <br /> hl <br />