Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTRAOARD V � TS m <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAMo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION � <br /> C lFOR��P <br />+- COMPLETE THIS FORM FOR EACH F CILITY/SITE ❑ 7 PERMNENT -- <br /> ALOSEO SITE <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOBURE <br /> iG <br /> I. FACILITY/SITE INFORMATION & ADDRESS — ( T E COMPLETED) <br /> CAR OF ADDRESS INFORMATION <br /> Y� <br /> FACILITY/SITE NAME O✓�-_ <br /> N <br /> NEAREST CROSS STREET ✓ or.PORAate 0 W(AL-ASHIP 0 FEDERAL <br /> AGENCY COAPOAAiIDN ❑ LOCALAGENCt ❑ FEDERAL AGENCY <br /> ADDRESS /,2 ,417 # 'r��/� 0 INDIVIDUAL ❑ GOUNIYAGENCY <br /> CITY NAME S7 V„ STATE ZIP CODE' SITE PONE p�WITH AREA CODE � �1 <br /> J lI C,1�701� CA J` liV 66 3 <br /> TYPEOFBUSINESS: ❑2 DISTRIBUTOR 04 ROCESSOR I/Box if INDIAN EPA ID # #of TANK's f� <br /> RESERVATION or ❑ AT THIS SITE <br /> ❑ I GASSTATION ❑ 3 FARM 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(SECONDARY) <br /> EMERGENCY CONTACT PERSON(PRIMARY) <br /> PHONE N WITH AREA CODE <br /> DAYS: NAME(AST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> (YI n91 W — 66-387 /S <br /> NIGHTS. NAME(LAST,F19 T. PHONE N WITH/AREA CODE NIGHTS: NAME(L ST.FIRST) <br /> PHONE p WITH AREA CODE <br /> flet AdAdIIII/ <br /> �N� b_ <br /> IL PROPERTY OWNE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> IVA65,It "1,11 MAILING or STREET ADDRESS ox to Intlicate Cl PARTNERSHIP 0 STATE-AGENCY <br /> I/U ,/ CORPORATION Cl LOCAL-AGENCY <br /> INDIVIDUAL [I FEDERAL AGENCY <br /> ^J Z ❑ [ICOUNTY-AGENCY <br /> CIN NAME L STAT ZIP COD PHONE H,WIT=AREA CODE / <br /> 66- <br /> KAI <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME ♦ ` / Aa C h 4--p <br /> ,l,M1G._1 rj(III'✓! ./ to,nd,cattee F-�❑0 PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or SjREL_T ADORES) ` /'-Tr��,A_ � ( IG,fCORPORATION ❑ LOCAL AGENCY ❑ FEDERALAGENCY <br /> Z ( iJ W V,_ LYV ❑ INDIVIDUAL 0 COUNTYAGENCY <br /> STATE - ZIP CODE / PHONE N,WITH AREA CODE <br /> CITU NAME 06 <br /> S mock <br /> IV. LEGAL NOTIFICATION AND BILL NG ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ III.El <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE <br /> 0 � 0 <br /> APPROVED BY N E� PHONE#WITH AREA CODE <br /> CURRENT LOCAL AGENCY FACILITY IO# wLVA Iz <br /> PERMIT NUMBER <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIO//per/CO E CENSUS TRACT# SUPERVISOR- (STRICT CODE BUSINESS YPELSN FILED NG ❑ DATE FIL i�� /)JQ <br /> V71 RECEIPT <br /> CHECK# PERMI AMOUNT SURCHARGE AMOUNT FEE CODE <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) • <br /> DATA PROCESSING COPY I W S <br />