Laserfiche WebLink
STATE OF CALIFORNIA ATER RESOURCES CO TROL B ARD <br /> Q - s� <br /> FORM 'AS. <br /> UNDE ROUND STORAGE TANK PROGRAM s <br /> SITE FACILITY/ E, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW RMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION NTLY CLOSED SITE <br /> ONE ITEM 2 I ERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE r r <br /> Cn <br /> I. FACILITY/SITE INF RMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NA C CARE OF ADDRESS INFORMATION <br /> ADRRES NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> '% r / Q/ Cl CORPORA71ON ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> /� 'J 4 © ❑ INDIVIDUAL ❑ G6ldNttAGENCY <br /> CITY NAME � STATE ZIP CODE _7b� SITE PHONE q,WITH AREA ODE <br /> ol <br /> A <br /> 3.y � <br /> # <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR d PROCESSOR ✓ EPA ID Box if INDIAN #of TpNK's <br /> RESERTION <br /> ❑ 1 GASSTATION ❑ 8 FARM <br /> OTHER TRUST LANDS or ❑ AT THIS SITE <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 /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#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 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGFNCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK 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 ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.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. ❑ if. ❑ III. ❑ <br /> THfS 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 10, 0 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> -' <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> CHECK* PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOWP4NIED BY AT LEA OR MORE TANK PERMIT FORM `B'APPLICATION($), SS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> RM A(3-2-88) J <br /> \ �� DATA PROCESSING COPY <br />