Laserfiche WebLink
STATE OF CALIFORf WATER RESOURCES CONAL BOARD aF <br /> /SfP iu��rin J^,f S <br /> FORM `A': N <br /> UNDERGROUND STORAGE TANK PROGRAM " �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; I <br /> it <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 115 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7,DF"NENTLY CLOSED SITE I"'a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE JJ N <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) ul <br /> FACILITY/SITE N ME , . 4V /L } CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET Bm IQ iM.P 0 PARTNERSHIP 0 STATE AGENCY <br /> 0 A_ / CORPORATION 11LOCALAGEND 1-1REDEML-AGENCY <br /> /V ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME .S-11AI STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: F—] 2 DISTRIBUTOR F-14 PROCESSOR RESERVATION or ❑ EPA ID # 9 AT THIS SITE a <br /> E] I GAS STATION E] 3 FARM ❑ 5 OTHER TRUSTLANDS <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 /> E 2 p S4 <br /> NIGHTS: NAME(LAST,FIRST) PHONE p ITH AREA CODE NIGHTS: NAME(LAST,F ) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESSox to intlicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> CORPORATION 0 LOCALAGENCY0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME rf CARE OF ADDRESS INFORMATION <br /> 60 <br /> MAILING or STREET ADDRESS r I Q ox 10 intlicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME /11/„/ -� STATE ZIP <br /> �- ZIP CODE <br /> �J/� PHONE ft.WITH AREA CODE <br /> P�\7 / P/c/ C/N W <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ Ill. <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# JURISDICTION# AGENCY# FACILITY ID Of If of TANKS at SITE <br /> ® = = 10d 11 I;,_1 450 1.31 1010101 J <br /> CURRENT LOCAL AGENCY F, CILITY 19#_ / APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER NS PERMIT APPROVAL7, <br /> PERMIT EKPIRATIO An <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 0 YES NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE 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 ON <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />