Laserfiche WebLink
r <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD �� } <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM . _ ¢ o z ! <br /> and/or PERMIT APPLICATIONSITE FACILITY/SITE, INFORMATION <br /> COMPLETE THIS FORM FOR EACH FA 1LITY/SITE <br /> i <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE W <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE C CD <br /> 1.FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) CO i <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION i <br /> i <br /> ADDRESS NEAREST CROSS STREET ✓ S ❑ P ❑ SThTE hGENGY <br /> COAPORATIDN ❑ LOCAthGENCY ❑ FEDE#lA1AGENCY <br /> �!'�r, `, ' e ;I ❑ INDMDUAL ❑ C0111+IT1'hGENCi <br /> CITY NAME l.J v �L�V STATE. ZIP CODE _ SITE PHONE N,WITH AREA CODE <br /> CA c S q - <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTO ❑4 P Rrfl/E.8 <br /> ox i!INDIAN EPA ID n #of TANK's , <br /> THEA RVATIONor : AT THIS SfTEI GaSSTATI�N ❑3 FARM STLANQS ❑ 0 �� <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMEfiGENCY CONTACT PERSON(SECONDARY) <br /> PHONE N WITH AREA CODE DAYS:I NAME(LAST,FIRST) PHONE it WITH AREA CODE <br /> DAYS: NAME(LAST.FIRST) 1 � �.� �-2 �� �(� <br /> PHONE q WITH AREA CODE <br /> ME{LAST, <br /> NIGHTS: NAF ST) <br /> HONE 0 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> ri <br /> H. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Bo indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL- ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME I — <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME n� S � '. <br /> MAILING or STREET ADDRESS 3 ✓So,,to indicate ❑ PARTNERSHIP r_1 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> El INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE' ZIP CODE PHONE#.WITH AREA CODE <br /> CITY NAME <br /> d <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)SOI(INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR 130TH LEGAL NOTIFICATION AND BILLING: I. fl. ❑ ILL.1E] <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> y DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY IR# #of TANKS al SITE <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> CURRENT LOCAL AGENCY FACILITY ID# <br /> PERMIT NUMBER <br /> PERMIT.APPROVAL DATE PERMIT EXPIRATION DATE <br /> t LOCATION CODE CENSUS TRACT# SUPERVISOR-DISICT CODE SUSENESS PLAN FILED <br /> TRYES NO <br /> DATE FILED <br /> /l ^1 <br /> FEE COgE RECEIPT# BY: <br /> CHECK# PERMIT AMOUNT SURCHARGEE AMOUNT I <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEA' 'OR MORE TANK PERMIT FORM;`B'APPLICATION(S), II °SS THi5 IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(9-2-88) <br /> O NG COPY <br /> � � DATA PRR �.ES t <br />