WORK PLANS - Laserfiche WebLink

Home Browse Search

lowSTATE OF CALIFCviNIA WATER RESOURCES C..,*4TROL BOARD J A t 1 u: , FORM 'A': UNDERGROUND STORAGE TANK PROGRAM � -; INFORMATION and/or PERMIT A tow SITE APPLICATION /� FACILITY/SITE, COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F-11 NEW PERMIT ❑3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑7 PERMANTLY UCLO SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT B TEMPORARY SITE CLOSURE I.FACILITY/SITE INFORMATION A ADDRESS—(MUST BE COMPLETED) FACT 1TY/�3 NA�M.E /� (' CARE QF REBS INFORMATION I.r ��I.�K.L G!J / ' ADDRESS NEA ST CROSS STREET V so to❑ LOCAL-ASM pwWAW ❑ STATE AC�ENL7 /V~NJ ❑ N11vOtv1 ❑ 00"440CY ? ftw STATE ZIP ODE SITE PHO E WITH AREA CODE CITY NAME n CA ldrim Z i/ / TYPE70 BUSINESS: ❑p DISTRIBI)fOR /PROCESSOR ✓Box M INDIAN EPA ID N Q tel TANK'N •r r•�!pA$5fAT10N ❑3fARM ❑5OTtIER RESERVATION or ❑ N / AT THIS SITE OI EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) < PHONE�NKWITHREA CODE YS. N t:(LAST,FIRST) P NE N WITH AREA CODE DAYS: E(LAST.FIRST 1/+1 PHO E TH AREA CODE NIGHTS: AME(LAST.FIRST)pq) NE N WITH AREA CODE NIGHTS: NAME( FIRST) /1 11. PROPERTY OWNER INFORMATION S ADDRESS—(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME �' -i.•+ MAlll G or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ FEDERAL-AGENCY STATE-AGENCY 13❑ COINDRPORALON 0 LOCAL ❑ COUNTY AGENCY ❑ FEDERAL-AGENCY STATE ZIP CODE PHONE N.WITH AREA CODE CITY NAME .. III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME r'.•, ,. CARE OF ADDRESS INFORMATION ... MGENCY A INC or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ FEDERSTATEAL-AGENCY❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE N,WITH AREA CODE CITY NAME IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)SOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. 11. El III•❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY r C OUNTY If JURISDICTION R AGENCY t FACILITY ID If /If of TANKS at SITE 13111 F-1 Ll I I LJ OD �APP VIED By NAM PHONE N WITH AREA CODE 7�w AL AGENCY FACILITY 10•A ER PERMIT APPROVAL DATE PERMIT EX RATION DAT! ATE FILEDIH? CENSUS TRACT. SUPERVISOR-DItT111CT COD! BUBINEt Y$N F❑ILEO NOooQQ BY: PERMIT AMOUNT SURCHARGE AMOUNT FE!CODE RECEIPT N r mummmom 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 FORM A(3-2-68) ' DATA PROCESSING COPY L