Laserfiche WebLink
SE''auc���'.M1f <br /> STATE OF CALIFORNIP WATER RESOURCES CONTRO OARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> i f COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> C� 5 CHANGE OF INFORMATION E17 PERMANENTLY CLOSED SITE -4 <br /> 1 NEW PERMIT �3 RENEWAL PERMIT � <br /> MARK ONLY q AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> 00 <br /> ONE ITEM 2 INTERIM PERMIT —4 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE <br /> CARE <br /> COMPDLETED)INFORMATION <br /> FACILITY/SITE NAME e_ <br /> Cn +(r N S 1 ✓gpxta diUle NEO IP Cl STA7EAGENGY <br /> NEAREST GROSS STREET ❑ CORPORATION LOCALAGENCY ❑ FSOEMbAGENCY <br /> ADDRESS ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> E• STATE ZIP CODE / SITE PHONE#,WITH AREA CODE <br /> CITY NAME CA S33G 2 ! z3 ' () <br /> EPA ID # #of TANK'X <br /> TYP OF BUSINESS'. 2 DISTRIBUTOR 0 q PROCESSOR RESERVATION or ❑ AT THIS SITE <br /> I GASSTATION 3 FARM 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(SECOND Y' <br /> #wITH AREA CODE <br /> EMERGENCY CONTACT PERSON(PRIMARY PHONE X WITH AREA coDE DnYS. NAME(LAST,FIRST) <br /> DAYS NAM E(LAST.FIRST) -�3-310 N•IC- <br /> )� ` PHONE k WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST)Jim PHONE X WITH AREA CODE NIGHTS NAME(LAST,FIRST) <br /> �pl�j jokt-4 26 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> QJ ❑ STATE-AGENCY <br /> ✓Box to CORPORATION <br /> ❑ PARTNERSHIP El FEDERAL-AGENCY <br /> MAILING or STREET ADDRESS ❑ CORPORATION ❑ LOGAL-AGENCY <br /> GEN <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE <br /> ZIP CODE PHONE#,WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED)CARE OF INFORMATIONSS <br /> NAME <br /> as ✓Box to intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS ❑ CORPORATION ❑ LOCAL-AGENCY [I FEDERAL-AGENCY <br /> ❑ INOIVLOUAL ❑ COUNTY-AGENC PHONE#,WITH AREA CODE <br /> STATE ZIP COO, <br /> CITY NAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. El III.E]THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNODWTE DGE, IS TRUEE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY #of TANKS at SITE <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# <br /> 3 `l aK2, za El <br /> APPROVED BY NAME PHOONE#WITH AREA CODE <br /> CURRENT LOCAL AGENCY FACILITY ID X <br /> Wo II PERMIT EXPIRATION DATE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> DATE FILED <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED 7 <br /> /}G ( ,/� / YES NO ❑ / <br /> 17 2 3 (o r 3 6 RECEIPT# B <br /> CHECK# PERMIT AMOUNT <br /> SURCHARGE AMOUNT FEE CODE <br /> 1 <br /> IS IS A CHANGE OF SITE INFORMATION ONLY <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST OR MORE TANK PERMIT FORM 'B' APPLICATION(S�ESS TH / <br /> 1 I FORM A(3-2-88) • <br /> DATA PROCESSING COPY <br />