Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAMo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> G — __ __] <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE 0 <br /> X <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) W <br /> CAS <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> L I O! <br /> ADDRESS NEAREST CROSS STREET ✓Bmbitiuce 0 PARTNERSHIP 0 STATE AGENCY <br /> 0 CORFORAi GN [I LOCALRGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 0i AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE X,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: 2DISTRIBUTOR ❑ 4PROCESSOR I/Box if INDIAN EPA IDX Mof TANK'X <br /> RESERVATION or AT THIS SITE <br /> F__] 1 GAS STATION ❑3 FARM ❑5 OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE X WITH AREA CODE <br /> NIGHTS. NAME(LAST,FIRST) PHONE X WITH AREA CODE NIGHTS. NAME(I-AST,FIRST) PHONE X WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box tc mil,cate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE X.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. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY R FACILITY ID X X of TANKS at SITE <br /> 2 I 3 cp <br /> CURRENT LOCAL AGE2CENSUSTRACT# <br /> APPROVED BY NAME PHONE X WITH AREA CODE <br /> PERMIT NUMBERAPPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F LEDYES El NOCHECK X SURCHARGE AMOUNT FEE CODE RECEIPT <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), ESS THIS IS A CHANGE OF SITE INFORMATION ONL` <br /> / FORM A(3-2-88) /' J <br /> �/A"/ to �q�-I DATA PROCESSING COPY <br />