Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROLB ARD is <br /> "e° f <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM a s " <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION } ' " ' ! o <br /> COMPLETE THIS FORM FOR EACH FAC TY/SITE '`^s�•�ex-`"' <br /> MARK ONLY ❑ I NEWPERMIT ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERM NENTLYCL ED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 53 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE N E CARE OF ADDRESS INFORMATION <br /> S <br /> ADDRESS NEAREST CROSS STREET ✓a wMule ❑ PAATNERW ❑ STATE AGDx3Y <br /> ❑ COAPOIIATIDN ❑ LOCAL AGENCY ❑ ROOK AGENCY <br /> 142 ❑ INDIVIM ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑/PROCESSOR ✓Box if INDIAN EPA ID p If of TANK's <br /> ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLANDS ION Or ❑ AT THIS SITE <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 WIT H AREA CODE <br /> NIGHTSNAME(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 /> MAILING or STREET ADDRESS ✓80x to mmcate ❑ 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 /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to ie0icate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> _ 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STAIE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> HECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ if. ❑ 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) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY B JURISDICTION S AGENCY B FACILITY ID N IT of TANKS AI SITE <br /> CURRENT LOCAL AGENCY FACILITY ID F_ APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DIHTRICT CODE BUSINESS PLAN FILED DATE FI <br /> YES ❑ NO <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(11 OR MORE TANK PERMIT FORM '0' APPLICATION(S), UNTHIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> FORM AIT-?nN) <br /> d <br />