COMPLIANCE INFO_1996-2002 - Laserfiche WebLink

Home Browse Search

i STATE OF CALIFOR WATER RESOURCES CONTROL BOARD S-PE�q°� CP•• •'sy FORM `A': UNDERGROUND STORAGE TANK PROGRAM � m r �0 �_�. SITE � FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - �";�; a �o COMPLETE THIS FORM FOR EACH FACILITY/SITE "OF0 top. MARK ONLY ❑ T NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PE LOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El TEMPORARY SITE CLOSURE q%� I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) I" CIU FACILI /SITE NAME CARE OFADDRESS INFORMATION , - 4 7� A ADDRESS N REST CROSS STREET ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY F ERAI-A NCY j 11 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE/�� SITE COIN€#,�j AR�r CODE "fL�CA2�Uw CA S�r fJ 9 1j TYPE OF USINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # 11,of TANK's 1 GAS STATION 3 FARM 5 OTHER RESERVATION or AT THIS SITE(/ ❑ ❑ TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME LAS ,FIRST) PONE#WITH AREA ODE DAYS: NAME(LAST,FIRST) PHON It WITH AREA CODE 7, 51A NIGHTS: NAME(LAST,FIR ) A ONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHO E#WITH AREA CODE SVA 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME gSj�� CARED ADDRESS INFORMATION 1 ("/j MAILING or STREET ADDRESS ��JC�%'vWC�G�/�� ✓Box to indicate 1:1 PARTNERSHIP ClSTATE-AGENCY Z Ija 11 CORPORATION 1:1 LOCAL-AGENCY NCY I 11 INDIVIDUAL ❑ COUNTY-AGENCY F ERA G CITY NAME STATE ZIP CODE PHON ITH AREA CODE CA III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION i MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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: I. II. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE ® EI I 1 10 10 1 c � _LL 0 � � 13 1 [PE ENT LOCAL AGENCY FACILITY ID# APP- RQVED BY ME PHONE#WITH AREA CODE WM IT NUMBER PERMIT APPROVAL DATE PERMIT E PIRATION DATE TION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED O YES NO K# PE IT AMOUNT SURCHARGE A OUNT FEE CODE RECEIPT# BY: 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. FORMA(3-2-88) DATA PROCESSING COPY