Laserfiche WebLink
STATE OF CALIFORNI0 WATER RESOURCES CONTRAIOARD / <br /> 5fA a lie <br /> FORM 'A':SITE UNDERGROUND STORAGE TANK PROGRAM A, <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION _ <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ONE ITEM ❑ 7 P ITE '_L <br /> ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE -4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) 00 <br /> FACILITY/S4ON <br /> 00 <br /> CARE OF ADDRESS INFORMATIONADDRESS/" NEAREST CROSS STREET ✓Bmloi ule 0 PARTNEB&91P 0 STATE AGENCY <br /> • 0 CORPORATION 0 LOX AGENGY 0 FEDEMLAGENCY <br /> CITY NAME 0 INDIVIDUAL 0 COUNTYRGENCYro <br /> STATE P CODE SITE PHONE N,WITH AREA CODE <br /> TYPEOFBUC'A <br /> 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA l0 N <br /> ❑ I GAS 3 FARM ❑ 5 OTHER RESERVATION or - #of TANK'S <br /> TRUST LANDS ❑ 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) <br /> PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NA <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box 10 irr0icare 0 PARTNERSHIP <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> ❑ INDIVIDUAL 0 FEDERAL-AGENCY <br /> CITY NAME ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> `F ^„ CARE OF ADDRESS INFORMATION <br /> MAILING.,STREET ADDRESS ✓Box to iPd,c.e 0 PARTNERSHIP <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> CITY NAME 0 INDIVIDUAL 0 COUNTY- 0 FEDERAL-AGENCY <br /> AGENCY <br /> STATE ZIP CODE PHONE A.WITH AREA CODE <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. it <br /> ❑ 111.❑ <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# <br /> � If TANKS at SITE <br /> CURRENTL CAL AGE FAC LITY ID Set <br /> l(�t'��r� APPROVED BY NAME <br /> PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACTN SUPERVISOR-DISTRICT CODE <br /> n BUSINESS PLAN FILED DATE FILED <br /> .oz 2 YES NO ❑ �' <br /> CHECK# PERMIT AMOUNT SURCXAR EAMOUNT FEE CODE <br /> RECEIPT BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) • <br /> DATA PROCESSING COPY 0 <br />