Laserfiche WebLink
STATE OF CALIFORNbir WATER RESOURCES CONTRWBOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMAtQaY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q r <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓BmbidcYe ❑ PAAiNENR1IP D S'TATEWENCY <br /> /f ❑ CINPDRAl11Nl D UXALAGENCY D 9DETUL-AGENCY <br /> �l ❑ IIIGMO.ViL D cmwTYJiC cr <br /> CITY NAME STfA <br /> ZIP CODE SITE PHONE p,WITH AREA CODE <br /> a <br /> TYPE OF BUSINESS: [:j 2 DISTRIBUTOR ❑/PROCESSOR ✓Box II INDIAN EPA ID It N of TANIPF <br /> ESER❑ ATION <br /> 1 GAS STATION E:] 3 FARM OTHER TRUST LANDS dr ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS'. NAME(LAST.FIRST) PHONE p WITH AREA CODE <br /> T <br /> NIGHTS: NAME)LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER NfORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to md.cete D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE,WITH AREA CODE <br /> l <br /> 111. TANK OWNER INFORMATION ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH Ailli ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ U. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY XF 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 R JURISDICTION M AGENCY R FACILITY ID R If of TANKS BI SITE " <br /> 10101 / 1,2-10171 0100 <br /> CURRENT L AGENCY FACILITY ION APPROVED BY NAME PHONE F WITH AREA CODE <br /> E E a-a-- <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT <br /> ((If/^� SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> (�� p a3, a(J 3 ��� YES E] NO ❑ <br /> fj� `` - <br /> \ CHECK F PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT F BY: ('\ <br /> m 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. CK <br /> I ` FORM A(&2-M) _ `r / <br /> \\v`TVI, ` ✓� <br />