COMPLIANCE INFO_1987-1992 - Laserfiche WebLink

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STATE OF CALIFORIV FORM `A'• WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C/ COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE fin Gjg I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION I L. ( eo #ziw 15 N 0 - ✓ Box to indicate RPIPARTNERSHIP ❑ STATE -AGENCY El CORPORATION ElLOCAL-AGENCY❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY ADDRESS �/y� STATE NEAREST CROSS STREET p,„, bi- ✓ ndicate ❑PARTNERSHIP ❑ STATE -AGENCY CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ✓ SrE nrvl� it e ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY E ni DATE FILED STATE CA ZIP CODE °ISZ' Is 5 -2+-fb SITE PHONE #, WITH AREA CODE 2oq TYPE OF USINESS: F—]2 DISTRIBUTOR F__]4 PROCESSOR ✓ Box if INDIAN EPA ID # BY: 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRRUSTVLANIDS ON or ❑ # of TANK's AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST)PHONE # WITH AREA CODE 6ql DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE Q H u L.-rk El e_,_rv1 s) S---� I - Zl4oo "JA - NIGHTS: NAME (LAST, FIRS) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE /TtlCO OL --o OD. C100) II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETEDI NAME , CARE OF ADDRESS INFORMATION CAR OF ADDRESS INFORMATION I L. ( 5"e S MAILING or STREET ADDRESS `�• WA p t � J !' LN V� P, ✓ Box to indicate RPIPARTNERSHIP ❑ STATE -AGENCY El CORPORATION ElLOCAL-AGENCY❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE a PHONE #, WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAMn JURISDICTION # CAR OF ADDRESS INFORMATION FACILITY ID # # of %TANKS at SITE LO -Loi © 1 (. 1 Lo I L/ F0741 �J S UC,! /S PERMIT NUMBER MAILING or STREET ADDRESS �1 L �+ vlA Z000 S 19LAWS LY r✓ x to indicate El PARTNERSHIP ❑ STATE -AGENCY CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY°E SrE ZIP CODE P ONE #, WITH AREA CODE J� DATE FILED CHECK # Is 5 -2+-fb IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. i 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 APPLICANT'S NAME (PRINTED & SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYq# 1 JURISDICTION # AGENCY# FACILITY ID # # of %TANKS at SITE LO -Loi © 1 (. 1 Lo I L/ F0741 CURRENT LOCAL AGENCY FACILITY ID # Aeus AP ROVED BY NAMEPHONE # WITH AREA CODE Q ! I� Og PERMIT NUMBER PERMIT APPROVAL DATE I OERMIT tXPIRATION DATE LOCATI N CODE CENSUS TRACT # SUPERVISOR -DISTRICT CODE Lb � BUSINESS PLAN FILED YES ❑ NO ❑ DATE FILED CHECK # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT # BY: