Laserfiche WebLink
STATE OF CALIFORNIO WATER RESOURCES CONTROj@bARD <br /> FORM 'A': / UNDERGROUND STORAGE TANK PROGRAM <br /> SITE L/ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' <br /> COMPLETE THIS FORM FOR EACH FA ILITY/SITE `"�•oan <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED S17E <br /> ONE ITEM ❑2 INTERIM PERMIT- ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE ` <br /> 1. FACILITY/SITE INFORMATION A ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> frau <br /> ADDRESS NEAREST CROSS STREET ✓NmailNna ❑ PMTW" ❑ STATEAGENLY <br /> / CW MTON 11 LOCAL ASPIC ❑ TOM ABDO <br /> 93bO ct.J` 1ONDAL ❑ COUM AGFND <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> Y tv-� CA 9Sj�o C <br /> TYPE OF 6u5mESS: ❑2 DI OR ❑1 PROCESSOR ✓BOx A INDIATIOSAN EPA ID N <br /> E_ GAS STATION ' 3 F WFW ❑5 OTHER <br /> RESEEgERVATION <br /> a ❑ AT T Il lI <br /> AT TNI{{ITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> U/C 4' L r_L li / :5 ?�;' -YS <br /> NIGHTS. NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Su "-P <br /> MAILING or STREET ADDRESS ✓Box W indicele ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY O FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SScY r"g <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 N.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. ❑ 111. ❑ <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 /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at 81TE <br /> 3 9 = = o Y o 3 C) I )I o I c- <br /> CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE N WITH AREA CODE <br /> /0/.9& /1'/=—(;�' <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACTS SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> _ Yv 3a3 3 ;)_� YESE] NO 90 <br /> CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPTS BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. " <br /> I lAiM A,,L ddl <br /> U <br /> V <br /> C <br />