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I <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> W <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM = � s <br /> FACILITY/SIT <br /> SIT E, INFORMATION and/or PERMIT APPLICATION <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION T PERMA NTLY CLOSED SITE 7j <br /> ONE ITEM E] p INTERIM PERMIT ❑4 AMENDED PERMIT [:]6 TEMPORARY SITE CLOSURE SQ <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> S d S wvvi ro �'n C <br /> ADDRESS NEAREST CROSS STREET ✓Bmw.*# El PARTNERSHIP El STATE AGM <br /> ❑ caPOAL El <br /> ClA13Eeoenal AGENCY <br /> ❑ CORPO <br /> RLIu LOCAL AGENCY <br /> ENGENcr <br /> CITY NAME ^ �vSTATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CAI � z; <br /> an I <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 P ESSOR ✓Box it INDIAN EPA ID # <br /> ❑ 1 GAS STATION ❑3 FARM OTHER RESERVATION or K M of TANK'# <br /> TRUSTLANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & DRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE I ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUkT BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(T)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOT (CATION AND BILLING: L ❑ 11. ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BES OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION N AGENCY R FACILITY ID# #of TANKS at SITE <br /> 0 OO <br /> CURRENT LOCAL AGENCY FACILITY ID It APPROVED BY NAME PHONE K WITH AREA CODE <br /> I <br /> PERM IT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION/CODE CENSUSTMGTII SUPERVISOR-OIICT GODS BUSINESS PLAN FILED NO <br /> ❑ TE�LEO ��T�'� <br /> I 3 -b <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# B <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1LOR MORE TANK PERMIT FORM `B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL . <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY J <br />