Laserfiche WebLink
1 <br /> STATE OF CALIFORNIA' WATER RESOURCES CONTRO1440ARD sE^.:;�; '"E <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'wona�F <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT S CHANGE OF INFORMATION ERMANENTLY CLOSED SITE <br /> ONE ---I <br /> ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY S1TE CLOSURE b'r) ` 4 <br /> (/ V1 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓ twoo ❑ PARTNERSHIP [ STATEAGBO <br /> on mwy2 ^ , MTIW ❑ LMAGENCY ❑ FEDE4ALAGE1x.Y <br /> A.-�IfA INDMWAL ❑ WDNTYAuSig <br /> CITY NAM STATEcA P ODZIE SITE PHONE a,WITH AREA CODE <br /> �c. .2 <br /> TYPE OF BUSINESS: F-12 DISTRIBUTOR E] 4 PROCESSOR ✓Box if INDIAN EPA 10 a <br /> RESErs <br /> ❑ T GAB STATION ❑3 FARM 5 OTHER TRUSTVLANDS ATION or ❑ AT THIf of IS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAY;. NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> Cle"le, -e— 2o?-aa-zija &K <br /> NIGHTS: NAME(LAST.FIRST) PHONE If WITH AREA CODE NIGHTS: NAME LAST,FIRST) PHONE If WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> s-f Scl� Eche f_.e-e— <br /> MAILING or STREET ADDRESS ✓ ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �O. / /O RPORATION ❑ LOCAL-AGENCY 13FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME ` STATE ZIP CODE PHONE N,WITH AREA ODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) (J—rJ70l9 <br /> NAME CARE OF ADDRESS INFORMATION <br /> AS <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,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. ❑ 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 /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION V AGENCY R FACILITY ID B R of TANKS N SITE <br /> O o 3 olololol <br /> CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE t WITH AREA CODE <br /> E>Asrs II x <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 41/ YES NO C / 6 <br /> CHECK♦ PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(SI, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> / �FgORM A(3-2-88) <br />'1T71'll'L\IYtJ1..L'bl DATA PROCESSING COPY � C <br /> Y <br />