Laserfiche WebLink
STATE OF CALIFORNIO WATER RESOURCES CONTROARD yoF <br />E RFK1 �•,yFp <br />FORM `A': <br />UNDERGROUND STORAGE TANK PROGRAM <br />SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION; a <br />C, COMPLETE THIS FORM FOR EACH FACILITY/SITE °"� FORN P <br />MARK ONLY ❑ 1 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 <br />1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />FACILITY/SITE NAME <br />'CO, <br />ear L <br />CARE OF ADDRESS INFORMATION <br />MAILING or STRE ADDRESS <br />h to <br />UJ &S <br />❑ STATE -AGENCY <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />ADDRESS <br />I , / <br />NEAREST CROSS STREET <br />✓Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />❑ C99DORATION ❑ El FEDERAL -AGENCY <br />❑ COUNTY -AGENCY <br />PHONE #, WITH AREA CODE <br />CITY NAME <br />S -F o c, K4i� <br />[�rNDIVIDUAL Cl COUNTY -AGENCY <br />COUNTY -AGENCY <br />CITY NAME <br />T v' v <br />STATE <br />CA <br />ZIP ODE <br />SURCHARGE AMOUNT <br />SITE PHONE #, WITH AREA CODE <br />TYPE OF BUSINESS: <br />❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR <br />I */Box if INDIAN <br />LANDS or <br />EPA ID #RESERATION /�Q <br />3 <br />1 GAS STATION <br />3 FARM 5 OTHER <br />[:]❑ <br />TRUST El/l/aw <br />G <br />AT THIS SITE <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />e <br />_ Remo -26 05-0 <br />NIGHTS: r4AME (LAW, <br />FIRST #WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />//''..PS�H„„ON <br />l¢(J —6 <br />II. PROPERTY 6WNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />NAME L 1/ lC�_P_fll/ T <br />CARE OF ADDRESS INFORMATION <br />�"'' <br />Jf)jjm),0_rtSj `p—r <br />MAILING or STRE ADDRESS <br />✓ Box to indicate <br />❑ PARTNERSHIP <br />❑ STATE -AGENCY <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />EQ1 CpRPORATION <br />Cl LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />r / <br />•LPINDIVIDUAL <br />❑ COUNTY -AGENCY <br />PHONE #, WITH AREA CODE <br />CITY NAME <br />S -F o c, K4i� <br />STATE <br />C q <br />ZIP CODEA <br />1 0 `� <br />ONE #, WITH AREA CODE <br />dq <br />III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />�"'' <br />Jf)jjm),0_rtSj `p—r <br />FACILITY ID # # of TANKS at SITE <br />0 0 / l f 1 c� o a_3AGENCY <br />MAILING or STREET ADDRESS <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />APPROVED BY NAME PHONE # WITH AREA CODE <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />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: I. 11. ❑ 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 />F <br />JURISDICTION # <br />AGENCY# <br />FACILITY ID # # of TANKS at SITE <br />0 0 / l f 1 c� o a_3AGENCY <br />FACILITY ID # <br />APPROVED BY NAME PHONE # WITH AREA CODE <br />PERMIT NUMBER <br />PERMIT APPROVAL DATE <br />PERMIT EXPIRATION DATE <br />LOCATION CODE <br />Of <br />CENSUS TRAQT # <br />aYES <br />SUPERVISOR -DISTRICT CODE <br />U <br />BUSINESS PLAN FILED <br />❑ NO <br />❑ <br />DATE FILED, <br />CHECK # <br />PERMIT AMOUNT <br />SURCHARGE AMOUNT <br />FEE CODE <br />RECEIPT # <br />I <br />I B . <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE TANK PERMIT FORM 'B' AgPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br />RM A (3-2-88) ft f <br />DATA PROCESSING COPY <br />