Laserfiche WebLink
i . <br /> STATE OF CALIFORNit <br /> WATER RESOURCES CONTR BOARD <br /> FORMW:. _ <br /> UNDERGROUND STORAGE TANK PROGRAM ° z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I c <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> i MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT DI(CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED�� � <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 cr <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) (7) <br /> CARE OF ADDRESS INFORMATION <br /> FACIDTY/SITE NAME <br /> -^YNctN l�f <br /> fs Lq JOrT'.'vSPI'li <br /> j ADDRESS NEAREST CROSS ST EET ❑✓COWRATION O Pmmiff nLWL � Q i1E00l4L AGSICY <br /> 0 INOMWAL ❑ COUNTY AGFNGY <br /> CITY NAME J f STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> S OC + l-j CA 5330- 17.2 ^off —4/23 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 4 PROCESSOR ✓Box ii INDIAN EPA ID N N of TANK'* <br /> ON <br /> I <br /> ❑ 1 GASSTATION ❑ S FARM ❑ 5 OTHER TRUST LANDS or ❑ AT TNIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> GAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> $'orPnJSr�N <br /> NIGHTS: NAME(LAST.FI Be) PHONE*WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE*WITH AREA CODE <br /> 2 09-823-30b' <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> oQt MF6- Co Cci $'o <br /> MAILING or STREET ADDRESS ✓ ax to mdic Ie ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Q Ok INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMEr STATE ZIP CODE PHONE A.WITH AREA CODE <br /> oP TD IJ fa gxsD <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> QS <br /> MAILING°r STREET ADDRESS ✓Sox Io indicate El PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE M,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. ❑ it. 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 N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> HE = t <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL EQATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT* SUPERVRICT CODE BUSINESS PLAN FILED DATE FILED <br /> . -3 YES NO ❑ �( , <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> G <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 />