Laserfiche WebLink
STATE OF CALIFORNIP WATER RESOURCES CONTROL�BOARD <br /> a <br /> ALL. <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM m" <br /> S FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , <br /> t� <br /> G COMPLETE THIS FORM FOR EAC ACILITY/SITE "P <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 6 T] <br /> 10 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> rh o 2 S , L/Ne 5 r\)ADDRESS NEAREST CROSS STREET IanNvale ❑ PARTNERSHIP 01 STA iE-AGENCY <br /> CORPORATION 01 [ILOCALAGENCY FEDERAL-AGENCY <br /> /�� Pi /i✓/.>0�—l✓ ❑ INDIVIDUAL ❑ COUNW AGENCY CQ <br /> CITY NAME ^ v� <br /> STATE ZIP CODE/ SITE <br /> ��PHONE' WITA CODE <br /> H AR Q� <br /> TYPE OF BUSINESS:G\� 2 DISTRIBUTOR 4 ROCESSOR ✓Box if INDIAN EPA NO 4 j� S #of TANK's <br /> ❑ ❑ RESERVATION or ❑ �V AT TNIS SITE <br /> ❑ i GAS STATION ❑ 3 FARM �5 OTHER TRUST LANDS <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 /> ALL, 1 <br /> NIGHTS: NAME(LAST,FIRR1) PHONE#WITH AREA CODE NIGHTS: NAME(LAST FAST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWN R INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S*- LrN <br /> MAILING 0,S REET ADDRESS ox to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> P. V„, O ' 0 p CORPORATION ❑ LOCAL-AGENCY ElFEDERAL AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> STATE ZIP CODE PHO^E#�T-ARE��—�� <br /> CITY NAME DE <br /> A-M � /^_ L✓ 9 <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME ,yam CARE OF ADDRESS INFORMATION <br /> �jG�lwe GCS /o UW <br /> Aet <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <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 /> 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# JURISDICTION OF AGENCYIN FACILITY ID# #of TANKS at SITE <br /> [� 0 10 111 il� o 10 1 � L <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 0IS <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> S— s—I <br /> LOCATIOON CODE CENSUS ACT MO SUPERVISOR-DISTRICT CODE BUSINESS PSN FILED NO <br /> ❑ DATE FIL 3 <br /> I i? <br /> EJ <br /> IF <br /> CHECK# PERMIT AMOUNT SURCHA GE AMOUNT FEE CODE RECEIPT# BY: <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 /> FORM A(3-2-88) 0 <br /> DATA PROCESSING COPY <br />