Laserfiche WebLink
OF <br /> STATE <br /> CALIFORNIA WATER RESOURCES CONTROL BOARD q � <br /> FOR `A'•. UNDERGROUND STORAGE TANK PR®GRA o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ®o; <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> ❑3 RENEWAL PERMIT CHANGE OF INFORMATION j MAN ED SITE <br /> MARK ONLY ❑I NEW PERMIT <br /> ONE ITEM ❑2 INTERIM PERMIT <br /> ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> FACILITY/SITE NAME / <br /> C g <br /> NEAREST CROSS STREET ✓Bozbadcate ❑ PARTNE11S1iIP ❑ STATE•AGE#C1 <br /> CpiB <br /> ADDRESS ,+ ❑ ORATIINd ❑ LOCAL-AGEDERAL <br /> ( ❑ FED •AGEtdCY <br /> JC 0 ❑ INDI410UAL ❑ COUNTY•AGENCY <br /> STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> CITY NAME CA S'2 <br /> Box i1 INDIAN EPA ID# #of TANK a <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR RESERVATION or ❑ AT THIS SITE <br /> ❑ 1 GAS STATION ❑3 FARM ❑5 OTHER TRUST LANDS <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 /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS—(MUST BECARE OFDDRESS COMPLLETEoD) <br /> NAME <br /> Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CITY NAME <br /> 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPDRLETEDCARE OF ESS MATtoN <br /> NAME <br /> Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS CORPORATION <br /> ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> _71 1 <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CITY NAME <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: I. ❑ 11. El III•❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> =APPLICANT'SNAME 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY - <br /> COUNTY# JURISDICTION# <br /> AGENCY# FACILITY ID If #of TANKS at SITE <br /> EH <br /> Em <br /> APPROVED BY NA <br /> ME PHONE#WITH AREA CODE <br /> CURRENT LOCAL AGENCY F ILITY 10# <br /> PERMIT NUMBER <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> DATE FILED <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DIS RICT CODE BUSINESS E N®ED NO ® � ® 0 <br /> CHECK# PERMIT AMOUNT SURCHARG MOUNT FEE CODE <br /> RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST Ill OR MORE TANK PERMIT FORM `B'APPLICATION(S),U ESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> ORM A(3-2-88) V) <br /> (� DATA PROCESSING COPY <br />