Laserfiche WebLink
WATER RESOURCES CONTROL BOARD <br /> STATE OF CALIFOR <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> and/or PERMIT APPLICATION <br /> FACILITY/SITE, INFORMATIONCATION <br /> SITE // FACT , <br /> COMPLETE THIS FORM FOR EACH/AGILITY/SITE - " <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El7NENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ a AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS -(MUST BE COMPLETED) <br /> FACILITY/SITE NAME / //li A//It"x5 CARE OF ADDRESS INFORMATION <br /> NEAREST CROSS STREET GO PORA CORPORATION � LOG11EAGEICT O FEDPAAL AG NCY <br /> ADDRESS / / — <br /> /Y p� / //� ❑ INDIVIDUAL ❑PEON <br /> rt,WITH <br /> /r— !ll��� CY <br /> STATE ZIP CODE .� SITE PHONE p,WITH AREA CODE <br /> CITY NAME <7 <br /> EPA ID N Mol TANK'S <br /> TYPE DF auSNJE55: 2 DISTPIBOTOfl ❑ 4 PROCESSOR RESERBoxVATIONIA°r AT THIS SITE <br /> ❑ I GAS STATION ❑ 3 FARM ❑5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> . PHONE N WITH AREA CODE DAYS'. NAME(LAST.FIRST) <br /> PHONE N WITH AREA CODE <br /> DAYSNAME(LAST,FIRST) <br /> A CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) <br /> PHONE N WITH ARE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE FADDRESS INFORMATION <br /> NAME <br /> ✓Box 1°Intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N,WITH AREA CODE <br /> CIN NAME <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE 01:ADDRESS INFORMATION <br /> NAME <br /> ✓Box 1°inoicale ❑ PARTNERSHIP Cl STATE AGENCY <br /> MAILING or STREET ADDRESS ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL Cl COUNTY AGENCY <br /> STATE ZIP CODE PHONE N,WITH AREA CODE <br /> CITY NAME <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 /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> FACILITY IDN 7atSITE <br /> COUNTYN JURISDICTION N AGENCYN CURRENT LOCAL AG Y FACILITY1D NAPPROVED BY NAME PH <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> DATE FILED <br /> LOCATION CODE CENSUB TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOU T FEE CODE YES ❑RECEIPTNMG ❑ BY: b <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-&B) <br /> DATA PROCESSING COPY <br />