Laserfiche WebLink
STATE OF CALIFORNI WATER RESOURCES CONTRIPBOARD <br /> FORM `A': P \, <br /> SITE UNDERGROUND STORAGE TANK PROGRAM u �m <br /> UlFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> O9lIFO eI,P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ONE ITEM E]2 INTERIM PERMIT ❑ T PERMANENTLY CLOSED SITE <br /> ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE C4(� <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) N <br /> JFACILITY/SITEN E <br /> CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> 7 NEAREST CROSS STREET ✓ me1 ❑ PARTNERSHIP ❑ STATEAGENCYpf CORPO 70N ❑ LOCAL.AGENCY ❑ FEpERALAGENCI <br /> CITY NAME ❑ INOP/IOOAL 13COUNTY AGENCY <br /> ZIP DE <br /> STATE _ SITE PHONE H.WITH AREA CODE <br /> TYPE OF BUSINESS: ❑2�DISTRIBUTOR 4 PROCESSOR '/Box if INDIAN EPA o ## <br /> ❑ T GAS STATION �d FARM ❑ 5 OTHER TRUSTRESERVLANDS or ❑ #oI TANMe „/ <br /> AT THIS SITE <br /> EMERGENCY CONTACT CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA COD DAYS: NAME(LAST FIRST) <br /> PHONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST <br /> HONE#WITH AREA CODE NIGHTS: NAM ST,FIRST) <br /> PHONE If WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STR AUDRESS ✓ xlo intlicale ❑ PARTNERSHIP <br /> CORPORATION ❑ LOCAL-AGENCY ❑ STATE-AGENCY <br /> CITY NAME ❑ INDIVIDUAL ❑ COUNTY- FEDERAL-AGENCY <br /> AGENCY <br /> STATE ZIP CODE PH NE#, ITH AREA CODE <br /> T <br /> 111. TANK OWNER INFORMATI N & ADDRESS - (MUST BE COMPLETED) ' <br /> NAME <br /> / CARE OF ADDRESS INFORMATION <br /> MAILING Or STREET ADDRESS vZ ✓Box to Intlicale ❑ PARTNERSHIP <br /> El CORPORATION ❑ LOCAL-AGENCY Cl13 SEATS-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCYFEDERAL-AGENCY <br /> CITU NAME <br /> 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: I. ❑ If <br /> 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) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID It <br /> #of TANKS at SITE <br /> CSU OOC� <br /> CURRENT LOCAL AGENCY FACILITY ID# <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACTP'. SUPERVISOR-DISTRICT CODE <br /> I? (u BUSINESS PLAN FILED DATE FILE <br /> / , YES NO 11 <br /> CNECK# PERMIT AMOUNT SURCHARGE AMOUNT <br /> 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) <br /> 0 DATA PROBING COPY r C <br />