Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROLOARD <br /> FORM 'A': '- m <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITEI FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 117 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ^`--a-"-" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El PERMANE LY CLOSED SITE <br /> ONE ITEM El INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I C <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> w V #�f ch4ell ow, <br /> ADDRESSNEARES—SCROSS STREET Indite ❑ PARTNERSHIP ElSTATE-AGENCY <br /> CORPORATION 11 LOCAL AGENCY ❑ FEDERAL AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SI PHO E#.WITH AREA CODE <br /> cA 33 0 .2 -�l7 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR -/Box it INDIAN EPA ID # <br /> RESERVATION or #of HIS SI <br /> ❑ 7 GAS STATION ❑ 3 FARM ❑ S OTHER TRUST LANDS ❑ AT THIS SITE <br /> 34 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> of � 707 f5"�to9 d2 C S Li a <br /> NIGHTS: NAME(LAST,FIRST PHONE#WITH AREA CODE NIGHTS. NAME(LAS .FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> lv/ o ✓&7e— <br /> MAILINGorSTREET ADDRESS �✓Bo34o indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Ly-CbRPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NA: STATE ZIP CODE P ONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CAPE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS s/Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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: U ❑ 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 R JURISDICTION# AGENCY# FACILITY ID# M of TANKS at SITE <br /> O ! 19 1 lo I 10 <br /> CURRENTLOCAL AGENCY FACILITY ID# APPROVED BY N%ME PHONE#WITH AREA CODE <br /> v %U Oc SS <br /> PERMIT NUMBER PERMIT APPROVAL/DATE <br /> PERMIT EXPIRATION DATE <br /> /V N <br /> LOCATION C2PE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESSPLAN FILED NO ❑ DATEFI D <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 /> FORMA(3-2-88) <br /> 0 DATA PROCESSING COPY <br />