Laserfiche WebLink
STATE OF CALIFORNI10 WATER RESOURCES CONTROROARD <br /> A <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -� to <br /> E e <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Efr7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) GTI <br /> GTI <br /> FACILITY/SI AME fCARE OF ADDRE SINFORMATION <br /> anCv a e- C <br /> ADDRESS NEAREST CROSS ST EET ✓Bm to iMioele ❑ PARTNERSHIP ❑ STATE AGENCY <br /> OAPOAATION ❑ LOCAL ❑ FEDERAL-AGENCY <br /> J GY INOMOUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> Lock-_ CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Be.it INDIAN EPA ID # <br /> RESERVATION or #of TANK's <br /> ❑ I GAS STATION ❑ 3 FARM E�JS.BRIER TRUST LANDS ❑ �- ATTHISSITE <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 /> Q�l cze� R(fI -fS <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME.&�AST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME \ CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEOERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE it,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It.WITH AREA CODE <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. II. ❑ 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 /> c-� <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID If IT,of TANKS at SITE <br /> [m = = - IIOD1010 <br /> CURRENT LOCAL AGENC CI��\l LyTY 10# APPROVED 8Y NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT`APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TPAC� O SUPERVISOR-DISTRICT <br /> (JOE OOE BUSINES PLAIN <br /> S NFILED NO ❑ DATE FILED I <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# `��L1/BY':W\ 4 <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 /> DATA PROCESSING COPY <br />