Laserfiche WebLink
STATE OF CALIFOR <br /> WATER RESOURCES CONT <br /> L BOARD <br /> FORM `A': s <br /> UNDERGROUND STORAGE TANK PROGRAM w <br /> SITE F41 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE c`Fo ,P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ' <br /> ONE ITEM ❑ 7 PERMANENTLY CLOSED SITE <br /> ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) y. <br /> FA ITY/S TE NAME �- <br /> _ /—� Q - % ( CARE ADDRESS INFORMATION <br /> ADDR S <br /> NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> VVVV ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAM ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> R J� t STATE ZIP CCOD 7TE PHO E It WITH AREA CODE. <br /> TYPE OF BUSINESS: CA <br /> ❑ 2 DISTRIBUTOR ❑4 p 9CESSOR ✓Box if INDIAN EPA ID a <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER RESERVATION or �,, ))f #of TANK's <br /> TRUST LANDS / v/ IA AT THIS SITE 0 l <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,.FIRST) PHONE#WITH AREA CO(D,,/E DAYS: NAME(LAST,FIRST) <br /> z0g �tj�"` r—t / PHONE q WITH AREA CODE <br /> NIGHTS: NAME(LAST ST�/ ^ PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) <br /> �'WLCKI//./ ,A C P ONE#WITH AREA CODE <br /> ISI Y /� A <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NA i {.�f! CARE OFJkDRESS INFORMATION <br /> MA LIN or STREET A ESS ✓Box to indicate ❑ PARTNERSHIP <br /> ❑ STATE-AGENCY <br /> o ;31//6 ❑ NDRVIDUALION ❑ LOCAL-AGENCY F ERA -AGENCY <br /> CITY NAME <br /> El <br /> STATE ZIP CODE PHONE , ITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> A CARE OF ADDRESS INFORMATION <br /> MAILING or S REET ADDRESS ✓Box to indicate ❑ PARTNERSHIP <br /> El STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE [PHONE7#, TH 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) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# ILITY ID# <br /> lim #of TANKS at SITE <br /> = = <br /> OD 3 (p a � a � <br /> CURRENT LOCAL AGENCY FACILITY Ip#� APpq ED BY NAME`f CO✓ � PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIR ION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISgR-DISTRICT CODE <br /> �� -�C.J BUSINESS PLAN FILED 'DATE FILED <br /> [ YES ❑ NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT <br /> 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 0 <br /> FORMA(3-2-88) of <br /> DATA PROCE SSING COPY 0 <br />