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TWI <br />rl .-c—oF <br />STATE OF CALIFORNIa WATER RESOURCES CONTROL -BOARD <br />5; ""� <br />u P� A <br />FORM `A': UNDERGROUND STORAGE TANK PROGRAM ,Ao z <br />SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION,;;^!� a c' <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7,K4W*"TLY CLOSED SITE <br />ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE (qql <br />I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />FACILITY/SITE NAME/ <br />CARE OF ADDRESS INFORMATION <br />C <br />N / <br />n. L �,4 uY <br />MAILING or STREET ADDRESS <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />ADDRESS T <br />Z7 <br />NEAREST CROSS STREET <br />_v/Box to indicate <br />El <br />El PARTNERSHIP ❑ STATE -AGENCY <br />1:1 LOCAL -AGENCY ElFEDERAL-AGENCY <br />v ,e/vTL� AFL <br />5�STATE <br />STATE <br />11 INDIVIDUAL <br />❑ COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CaDE <br />SITE <br />PHONE It, WITH AREA CODE <br />PERMIT AMOUNT <br />CA <br />-037&1 <br />FEE CODE <br />= �� <br />TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR <br />✓ Box if INDI N <br />EPA ID # <br />❑ 1 GAS STATION [:]3 FARM ❑ 5 OTHER <br />RESERVATION or <br />TRUST LANDS ❑ <br /># of TANK's <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 />�6(r�c� <br />PHONE # WITH AREA CODE <br />d3 / <br />NIGHTS: NAME (LAST, FI ST) PHONE # WITH AREA CODE <br />NIGHTS: NAM (I - FIRST) <br />PHONE # WITH AREA CODE <br />PRUPENTY UVVNEN INFUNMATIUN & AUUNESS — (MUST 6E UUMPLETEU) <br />NAME CARE OF ADDRESS INFORMATION <br />' r <br />MAILING or STREET ADDR S %�� /,��( /% ,Q./�/ - /c ,(��) ✓ Box to indicate ARTNERSHIP ❑ STATE -AGENCY <br />CORPORAT�' " . V / e it / v % 4/ /V Z / � INDIVIDUAL El <br />El OUNTY AGENCY ❑ FEDERAL -AGENCY <br />CITY NAME STATE ,4_ZIP CODE PHONE #, WITH AREA CODE <br />III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />C <br />N / <br />FACILITY ID It /) /##of TANKS <br />atat)SITE <br />v[�j (� V V <br />D111.31 <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. If. ❑ 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 8 SIGNATURE) DATE <br />LOCAL AGENCY USE ONLY <br />COUNTY # <br />[a] <br />JURISDICTION # <br />I I I <br />AGENCY # <br />E[ 1 <br />FACILITY ID It /) /##of TANKS <br />atat)SITE <br />v[�j (� V V <br />D111.31 <br />CURRENT LOCAL AGENCY FACILITY ID k <br />SGO <br />APPROVED BY NAME PHONE #WITH AREA CODE <br />PERMIT NUMBER <br />PERMIT APPROVAL DATE <br />PERMIT EXPIRATION DATE <br />LOCATION C E <br />0 <br />CENSUS TRACT O - <br />f o <br />SUPERVISOR -DISTRICT CODE <br />BUSINESS PLAN FILED <br />YES ❑ NO ❑ <br />DATE FILED <br />S 4ff <br />CHECK # <br />PERMIT AMOUNT <br />SURCHARGE AMOUNT <br />FEE CODE <br />RECEIPT k <br />BY�/�� <br />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 0 ` y-. <br />FORM A (3-2-88) <br />DATA PROCESSING COSY <br />*�6 <br />OD <br />to <br />