Laserfiche WebLink
STATE OF CALIFORNIP WATER RESOURCESCONTROL'WOARD <br /> a 1 <br /> FORM A : <br /> UNDERGROUND STORAGE TANK PROGRAM = " o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE `'<ironx`r <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 10 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> L S <br /> ADDRESS NEAREST CROSS STREET ✓B to indicate ❑ PARTNERSHIP 0 STATE AGENCY IV <br /> 7 PS LQ� mQ(G ] Yl, L9�GPGRAnoN ❑ LGGALAGENCY ❑ RDERAL-AGENC( cn <br /> ❑ INDIVIDUAL 0 COUNTY AGENCY ,A <br /> CITY NAME STATE ZIP CODE SITE PHONE a,WITH AREA CODE <br /> S�ocl«wL CA 5aa ao9 l5a -/aaa <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Bax if INDIAN EPA ID a <br /> ❑ 1 GAS STATION ❑3 FAgM OTHER TRUST LANDS ATIONa ❑ tv O YL) 'e. #AT of HIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH OD <br /> AREA CODE DAYS'. NAME(LAST,FIRST) PHONE a WITH AREA CE <br /> -doh SGhm' AGIC 5a-laa � <br /> NIGHTS: NAME(LAST,FIRST) PHONE it WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> Same. <br /> IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SarnE as 5 /" fie <br /> MAILING o,STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION Cl LOCAL-AGENCY ❑ FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SQYnSi'e-e. <br /> MAILING o,STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCALAGENCY0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a.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: 1. CR it. ❑ 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 8 SIGNATURE) CATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYIN JURISDICTION# AGENCY# FACILITY ID If If of TANKS a1 SITE <br /> C- 6- / P5- 161DOl <br /> CURRENT LOCAL AGENCY FACILITY 10# APPROVED BY NAME PHONE#WITH AREA CODE <br /> ,6D <br /> PERMIT NUMBER PERMIT APPROVAL DATE PEflM1T EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED G <br /> Q a3• �O / YES NO � / SO <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 ONLY. <br /> FORM A(3-2-88) 0 <br /> DATA PROCESSING COPY <br />