SU0007710_SSCRPT - Laserfiche WebLink

Home Browse Search

*► l �� 0 S�t't'u s, 3 nemoc�dr I (.r�� STATE OF CALIFORNIA, WATER RESOURCES CONTROL -40ARD �� `......, FORM `A': '' UNDERGROUND STORAGE TANK PROGRAM =°` 2T ;SITE EQ FACILITY/SITE, INFORMATION and/Or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH,F CILITY/SITE c� •oaN`• MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 1 PERMANENTLY CLOSED SITE ONE ITEM El2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE g "L FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 7�Zr/vkL� X30 ys t3C�r`icrc�+.��-,�"� ADDRESS NEAREST CROSS STREET ✓Box to k,.,* ❑ PAgT11 ium ❑ STATE-AGOG Hul 33 o MD MTIONviAL a LOX X -WO 1(1 [IY FOUAL4CIN CITY NAME STATE ZIP GODE SITE PHONE N.WITH AREA CODE 7-rl4-C Y CA5� 7 6 TYPE OF BUSINESS ❑2 DISTRIBUTOR ❑ 4 PROCESSOR - VATION Box IINDIAN EPA ID N ❑ ANIC I GAS STATION ❑3 FARM U J OTHER TRUST LANDS ❑ A of tS A7 THHIS S SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE /V t L,&_ l c 09 P 5 -9&L(- NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 1)w# I& C1 O9 A?3 - J,30_2_ II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILM or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INOMDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 5- m e GAS ai�v U c_ a MAIUNG or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ��11. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY K JURISDICTION A AGENCY N FACILITY ID N A Of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID f APPROVED BY NAME PHONE 9 WITH AREA CODE -rk//v K 9 l PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT f SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES ❑ NO ❑ /-/7-aU CHECK f PERMIT AMOUNT SURCHAAGE AMOUNT FEE CODE RECEIPT f BY: T 1, THIS FORM MUST-IK ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONp, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-W)