Laserfiche WebLink
��Of <br /> F <br /> STATE OF CALI FO R N I WATER RESOURCES CONTROBOARD P:- ` "i ••.'� <br /> W l ;sA <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM kym <br /> SITE FACILITY/SITE INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> c ' e (LIE -o a S C o ry <br /> ADDRESS / NEAREST CROSS STREET�` v/Bo indicale El PARTNERSHIP ❑ STATE-AGENCY <br /> 9KO0 LOCAL-AGENCY <br /> 3 � n), 0 a11-11/ f �- )I d s a J�' ❑ INDMDUALON 1:1COUNTY AGENCY ❑ FEDERAL-AGENCY LTA <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> �K CA L7SoZb -i_ X0171f3- q0 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bax it INDIAN EPA ID # <br /> RESERVATION or �) #of T 15 <br /> ❑ 1 GAS STATION [:] 3 FARM OTHEA TRUST LANDS ❑ Iv O We— AT THIS SITE <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 /> Emet^ evl !� &vl tro I (`_"fer( /5)S-a -7777 <br /> NIGHTS: N (LAST,FIR PHONE#WITH AR A CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> SxnE. <br /> r <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> f ac ` 'c_ 13e /I <br /> P�if r 1 C t � r. <br /> MAILING or STREET ADDRESS /y y,,' /'�n L. ORPORATION ❑to indicate D LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> O'\4P 0 O Lia.m I Yti �a rn ,v F `��-+"' ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> �a Yl 12 Gi4 ?3 C Lf 15 i5',;�,3-1Ra3 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME I CARE OF ADDRESS INFORMATION <br /> pccf471`c i3e / if 66K.Sivo l=ueluN.% <br /> MAILING or STREET ADDRESSo indicate E3PARTNERSHIP ❑ STATE-AGENCY <br /> 8 <br /> ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> P. ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 'Fres C a <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. ❑ II. ❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> FPERN <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> �C� 18' � � � � O <br /> AGENCY FACILITY ID APPROVED BY NAME PHONE#WITH AREA CODE <br /> C <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED •�7 <br /> a3 1 $ YES E] NO Y-,fPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <br /> 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. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />