Laserfiche WebLink
- fl <br /> TTI­ <br /> STATE OF CALIFORNIP WATER RESOURCES CONTROL <br /> A <br /> FORM `A': m <br /> SITE (/ UNDERGROUND STORAGE TANK PROGRAM = � ° <br /> ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION °� 0 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'<nonN`P 7th <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 allIMANlEFFILY CLOSED SITE IV <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE / CA <br /> CTI <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> pru <br /> ADDRESS /1':—) 9/I� -fx/C/� �L(/� NEAREST CROSS STREET ✓Boxaindmie El PARTNERSHIP 11 STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> ❑ INOMDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ 4 PROCESSOR ✓Ba.It <br /> A INDIAN EPA ID n <br /> ❑ 1 GAS STATION ❑ 3 FARM E] 5 OTHER RESIt of TANK's <br /> TRUST LANDS RTIONGr ❑ AT THIS SITE (/ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAME(LAST,FIRST) <br /> �'iPHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> (/C2A f�h(TH`Da lfit-6s6�� �w�.-.ems <br /> NIGHTS. NAME(LAST, RST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMyEN l` (7 <br /> //�7 L, <br /> 0/v „,/v�_� n CARE OF ADDRESS INFORMATION <br /> MAILING Qor STREET ADDIR ,/`J '(7/ ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �S 3 1/ �A"I'Ll L ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> v ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME <br /> STATE ZIP CODE PHONE <br /> 1 lF,oWOir/T p,WITH AREA CODE <br /> K i763 2� <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> :F4`"-7 <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE 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 /> \�'CI -9- <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY41, FACILITY ID N If o1 TANKS at SITE <br /> 31 010 Zy pvo �- <br /> CURRENT LOCA SHE FACILITY ID p <br /> 7TAPPROVED BY NAME PHONE p WITH AREA CODE <br /> V�{CI S <br /> PERMIT NUMBER PERMIT APPRO E PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACpT p SUPERVISOR-DISTRICT CODE BUSINES,P S N FILED NO=FILED <br /> d VCHECKp PERMIT AMOUNT SURCHARGE qMO NT FEE CODE RECEIPTk <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEA 17 OR MORE TANK PERMIT FO R M 'BI APPLICATION(S)° SS THIS IS A CHANGE OF SITE INFORMATION ONLY. C <br /> FORM A(3-2.88) SK <br /> .vL �v DATA PROCESSING COPY <br /> Z7� <br />