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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> 1 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �'"•o^"'" y <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT I& CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 1 <br /> ONE ITEM ❑p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 5 ' <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) W <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION TTWw <br /> `V <br /> ADDRESS NEAREST CROSS STREET ✓Bab Miele Cl PARTNERSHIP 0 STATE AGENCY W <br /> 0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL AGENCY <br /> 0 IWMWAL 0 COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ <PROCESSOR ✓Box if INDIAN EPA 10 N <br /> RESERVATION or N of TANK'F / <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> ' CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) f <br /> NAME CARE OF ADDRESS INFORMATION I <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCV <br /> CITU NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> 'CHECK (1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION R AGENCY R FACILITY ID If k of TANKS at SITE <br /> 3 � L. I I EEUT0 <br /> CURRENT LOCAL AGENCY 71W ID Y APPROVED BY NAME <br /> PHONE N WITH AREA CODE <br /> T/t <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT Al <br /> SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> O) Z3, qo YES [j NO [:] I/ Z/ 5 <br /> CNECKa PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> RECEIPTN BY: <br /> ITHIS FORM MUST BE ACCOMPANIED BY AT YEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> / FOHM A(3-2-8, <br /> �\�'�"1.� " DATA PROCESSING COPY �.P 1 <br />