COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

ygP su osq T/YF STATE OF CALIFORNIP WATER RESOURCES CONTROIROARD �y m UNDERGROUND STORAGE TANK PROGRAM FACILITY/SITE, �A and/orSITE INFORMATION APPLICATION , COMPLETE THIS EMARK �g41FORN" ONLY ® 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE ITEM El A ENTLY CLOSED SITE 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATIONFACILITY/ — ) FACILITY/SITE NAME 6 Il CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Boz to inkme ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDMDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE CAr TYPE OF BUSINESS: 2 DISTRIBUTOR ® 4 PROCESSOR ✓Box if INDIAN EPA ID# RESERVATION or #of TANK: 1 GAS STATION 3 FARM 5 OTHER TRUST LANDS AT THIS SITE EMERGENCY TACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE a� �" NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAS ,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION ) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY 7 e ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP/CODE PHONE#,WITH AREA CODE d III. TANK OWNER INFORMATION NAME CARE OF ADDRESS INFORMATION Q � MAILING or STREET ADDRESS Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY 6 0 e ' p ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME ' STATE ZIP CODE PHONE#,WITH AREA CODE ® LEGAL NOTIFICATIONBILLING C ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. ® 111. 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 [PEE JURISDICTION# AGENCY# FACILITYI # #of TANKS at SITE LiA AGENCY FACILITY ID# PRO BY NAME PHONE#WITH AREA CODE A PERMIT RIT APPROVAL DATE PERMIT EXPIRATION DATE CENSUS ACT# SUPERVISOR-DISTRICT CO BUSINESSFILED DATE FILED (� YES NO PERMIT AMOUNT SURCHARGE AMOUNT CODE I I RECEIPT# BY: THIS FORM MUST BE ACCOMPAIIIIED BY AT LEAST(1)OR MORE TAPPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY FORM A(3-2-88)