Laserfiche WebLink
FORM `A': <br /> FACILITY/SITE, (LOCATION) INFORMATION and/or PERMIT APPLICATION <br /> ,--� UNDERGROUND STORAGE TANK PROGRAM No 636 <br /> COMPLETE A SEPARATE FORMA, FOR EACH UNIQUE FACILITY/SITE-(LOCATION) <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> (LOCATION OF TANKS) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> U 61.- t bal <br /> ADDRESS NEAREST CROSS STREET <br /> wf. 99 <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> TYPE OF BUSINESS: 1 GAS STATION ❑ 2 DISTRIBUTOR EPA ID# QQ'f #of TANK's at SITE <br /> ❑ 3 FARM TANK [:] 4 PROCESSOR ❑ 5 OTHER (AD % O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> hIN(4z-0,9 - v I l- 60015)$61-v7/y0 <br /> NIGHTS: NA (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST',FIRST) PHONE#WITH AREA CODE <br /> UNoLAI.,EMI�NU-C FHa1�EC4►5��6?-OZ60 LNa�P�-�Nt PNDtJ C4i5� 511-0160 <br /> II. TANK OWNER INFORMATION &ADDRESS— (COMPLETE ONLY IF DIFFERENT FROM ABOVE) <br /> NAME ;?r,^ CARE OF ADDRESS INFORMATION <br /> MoN OIL.,, e o. of e.4qjF0FRtQA, tJNo,PJ, <br /> MAILING or STREET ADDRESS <br /> 2a c,0 Gf-0W 4M-(ON PLP4y, pO <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 5A►v 94.5 83 44 e5) 5 e-1- 0-7 LO <br /> III. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> UN I oN clL, Co. OF fV I DSA lli L� <br /> MAILING or STREET ADDRESS <br /> -2�0' Irl CAN OJ4 *4-00 <br /> CITY NAME STATE ZIP CODE PHONE#,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: 1. ❑ II. � III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> AP ICANT' NAME RINTED&SIGNATURE) 400N 61 'gog�iS N- <br /> LOCAL AGENC SE ONLY I,SNaLAI—� <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 3L2-LoFT3T�UO1,01 <br /> CURRENT LOCAL AGENCY ID# <br /> N10N D <br /> CONTACT PERSON PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE <br /> LOCATION CODE CEN/SUSS�T(RRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN DATE FILED r� <br /> 02- G^JiVO 20 YES NO ❑ <br /> CHECK# AMOUNT FEE CODE RECEIPT# B� Y <br /> THIS FORM MUST BE ACCOMP IE T LEAS OR MORE FO R M B'S, 'TANK PERMIT FORMS',UNLTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> MA(1-88) a <br /> a_�o - \ DATA PROCESSING COPY <br />