Laserfiche WebLink
S 7A 7.1--_ O OF CA L I z O R���=+� WATER RESOURCES CONTROL BOARD <br /> F0RZ'�i A. <br /> � UNDERGROUND STORAGE TANX PROGRAM <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 2EAMA*_NTLY 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 CARE OF ADDRESS INFORMATION <br /> ADDRESS N EST CROSS STREEeCOWRATION <br /> _e PARTNERMP 1-1 STATEAGENCY <br /> aP � I LOCAL-AGENCY <br /> 11 FEDERALAGENCI <br /> CITY NAMENIOUAL COVNtt-AGENCY <br /> 7 e <br /> STATEA ZIP,GOD� � SITE rWITH�RFACO <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑OROCESSOR ✓Box ii INDIAN EPA ID a E�f t ! <br /> ❑ 1 GASSTATION ❑ 3 FARM �5 OTHER RESERVATION <br /> RUSR LANDS Or ❑ IF a1 TANK a <br /> ATTHISSITE -� <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) 4`4//PHONE a WITH <br /> �A/R�EAfODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> //-, �I / rl i/ ,(1'i f1 -� -I ' ' —Y L ifJ / /'�``'/ , -i�l s�yG — iG�`�.. 7 <br /> 4/6- <br /> .NIGHTS: NAME(LAST, ST) / PHONE a WITH AREA CODE NIGHTS. NAME(LAST, IRST) PHONE a WITH AREA CODE <br /> +J 41✓r 3 -{sem <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS Ll QM to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS- (;.'.UST BE COMPLETED) <br /> NAME _ CARE OF ADDRESS INFORMATION <br /> � i <br /> MAILING or STREET ADDRESy ox to indicate 1:3PARTNERSHIP ❑ STATE-AGENCY <br /> r% Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> /❑ INDIVIDUAL 11COUNTY-AGENCY <br /> CITY NAME 'S 711--1SL'TAT ZIP CODE I PHONE Pf SfWI'H AREACODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ACOVIS ADWZI3103 SHOULD BE USED FOR DOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 111. <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 /> COUNTY* JURISDICTION# AGENCY II FACILITY ID N� M o1 TANKS a1 SITE <br /> 1 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME/,' { PHONE N WITH AREA CODE, <br /> MIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> SDE CENSU�TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> `% :< J "fl ,f it YES a NO ❑ J <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE - RECEIPT a <br /> .:COL'PAHIED BY AT LEAST(1)OR VORE TANX PERL7IT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORVATION ONLY. <br /> '"• FILE COPY <br />