Laserfiche WebLink
STATE OF CALIFORNI.0 WATER RESOURCES CONTROMOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE �CILITY/SITE, INFORMATION and/or PER APPLICATION -� <br /> /�/ COMPLETE THIS FORM FOR EACH F ITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMAN NT SED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NA - CARE OF ADDRESS INFORMATION <br /> ADDRESS C NEAREST CROSS STREET ✓Swbrdi le ❑ PARTNERSHIP ❑ STATEAGENLY <br /> SSIO C - / G��H ❑ <br /> CORPORATION ❑ IGGAL-AGBILY O FFDFPALAGENCY <br /> ❑ INOPMIILUL ❑ fAUN1YAGENCY <br /> CIN NAME G STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA S�3 <br /> TYPE OF BUSINESS: Box if INDIAN EPA ID N B Of TANK'S <br /> E] ❑ 5 OTHER 2 DISTRIBLROR 4 PROCESSOR I TRUST LANDS-/RESERVATION or 1:1AT THIS SITE <br /> ❑ 1 GAS STATION [:] 3 FARM ❑ <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 WITH ARUCODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Sox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to hdicale ❑ 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 /> 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. ❑ II. ❑ 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 N JURISDICTION N AGENCYII FACILITY ID S N of TANKS At SITE " <br /> a I y `' <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> .e/GF/ !;, <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> PA(3-2-88) <br /> CENSUS"ACT 0 SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FlLED / <br /> YES NOPERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPrk BY:ACCOMPANIED BYATLEAST(1)OR MORETANKPERMIT FORM 'B'APPLICATION(S(, UNLESSTHIS ISACHANGE OFSITE INFORMATION OW <br /> 0 <br /> 0 <br />