COMPLIANCE INFO_1989-1998 - Laserfiche WebLink

Home Browse Search

- WATERSTATE OF CALIFORA L R. WP �A FORMW: UNDERGROUND STORAGE TANK PROGRAM _ .Ab9m SITE /SITE, INFORMATION and/or PERMIT APPLICATION-, COMPLETE THIS FORM FOR EACH (CILI /SITE CqG, FORK P ARK 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 M: 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION z ADDRESS NEAREST CROSS STREET ✓ Bac to ¢dam ❑ PARTNMV ❑ STATE -AGENCY ❑ 0WORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE SITE PHONE #, WITH AREA CODE Y 1 la 95 -,.l.> -5, .;)C?,/ m V& 3 Ci®/ V, TYPE OF SINESS: ® 2 DISTRIBUTOR ® 4 PROCESSOR ✓Box if INDIAN EPA ID # RESERVATION or ��LAT f TANK'• GAS STATION ® 3 FARM ❑ 5 OTHER TRUST LANDS ❑ (�{/ THIS SITE EMERGENCY CTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) g PHONE # WITH �AREA tCODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE `c NIGHTS: NAME (LAST. FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE s1_4 I NAME CARE OF ADDRESS INFORMATION A-12e-,�/-->`v sr /.e ms MAILING or STREET ADDRESS ✓ indicate ❑ PARTNERSHIP ❑ STATE -AGENCY / PORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ®O �i NDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE I ZIP CODE I PHONE #, WITH AREA CODE I11. TANK OWNER INFORMATION $ — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS indicate ❑ PARTNERSHIP ❑ STATE -AGENCY RPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY DIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE I ZIP CODE PHONE #, WITH AREA CODE IV. LEGAL NOTIFICATIONBILLING CHECK ONE (1) BOX INDICATING WNICN AlBOVFA SHOULD BE USED FOR BOTN LEGAL NOTIFICATION AND BILLING: I. E] II> ❑ IBI. ❑ 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) I DATE LOCALONLY THIS FOR UST ACCOMPANIED Y AT (1) OR ORE T AIT -APPLICATION(S), UNLESS THIS 15 A CHANGE OF SITE INFO ON ONLY. FORM A (3-2-88) PERMIT EXPIRATION DATE ,LOCATION CODE SUPERVISOR-4D)ISTMRI BUSINESS PLAN FILED PERMIT AMOUNT SURCHARGE AMOUNT THIS FOR UST ACCOMPANIED Y AT (1) OR ORE T AIT -APPLICATION(S), UNLESS THIS 15 A CHANGE OF SITE INFO ON ONLY. FORM A (3-2-88)