COMPLIANCE INFO_1987-1992 - Laserfiche WebLink

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STATE OF CALIFORNIA WATER RESOURCES CONTRJNOARD <; FORM `A': UNDERGROUND STORAGE TANK PROGRAM -w 'o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - _ o COMPLETE THIS FORM FOR EACH FA ILITY/SITE Cq IIFORN P MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 REaUAW-WILY CLOSED SITE N ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE —4 .J I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) N CTI FACILITY/SITE NAME CARE O DDRESS INFORMATION �_ n CCI��-G JZ10 l r 10 a ADDRESS NEAREST CROSS STREET ✓Bortoi to ❑ PARTNE IP ❑ STATE-AGENCY C RATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY S DIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CO E SITE PHONE#,WITH AREA CODE CA S� 0/1 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN I EPA ID # #of TANK's GAS STATION ❑3 FARM ❑ 5 OTHER LISTATION LANDS of ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME JLAST,FIRST) '/ PHONE#WITH AREA CODE Id -Z4 — 9 — Q� < � r �/ cv0 — 9 —�71 NIGHTS: NA E(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME ST,FIRST) PHONE#WITH AREA CODE 'tAv' ` �1—°b9 2-W/ II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME � r� I /�� CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS K ✓Box to indicate ❑ PARTNERSHIP ClSTATE-AGENCY/': d' ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY O 0 Q ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME i•"" STATE ZIP CODEPHONE#,WITH AREA CODE e 12s .S� III. TANK OWNER INFORMATION &ADDR S — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S Q. S MAILING or STREET ADDRESS ✓Bax 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. ❑ It. 1_5 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 FPERMITNUMBER JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE F7;Fl! I I I I I IL I I po ( C ? 0 D 0 AG NCY FACIL Yl # APPROVED BY NAME PHONE#WITH AREA CODE PE MIT APPROVAL DATE PERMIT EXPIRATION DATE CENSUSTRACT y� SUPERVISOR-DI RICT CODE BUSINESS PLAN FILED DATE ILED ^i V YES � NO � �s�PERMIT AMOUNT SURCHARGE A OUNT FEE CODE RECEIPT# BY: N ' 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