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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM -y✓t1 lila _ �" Z <br /> SIt <br /> �� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> " I o <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY LOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE CJJ` —4 <br /> N <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) CD <br /> O <br /> FACILI /SITE ME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓BRDAtrSe 0 PARINEW 0 STATE AGBILY' <br /> �� �, /I ClWROPATON 0 LOGL�AMV 0 REDEPAIAGE10 <br /> IrW M1.c� 0 INONIOLL 0 COUNWAGENC! <br /> CITY NAME STATE ZI CODE SITE PHONE#.WITH AREA CODE <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ d Pptf=R ✓Box if INDIAN EPA ID N If Y TANK'f <br /> ❑ 1 GAS STATION ❑ 7 FARM OTHER TRUSTVLANDS ATION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT RSON (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#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#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 STATE-AGENCY <br /> ❑ CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> Cl INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS \ ✓Box to Indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION C LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> j IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOYE ADDRESS SHOULD BE USED FOR BOTH tEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO E BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION N AGENCY R FACILITY ID N B of TANKS Y SITE <br /> [10106aa55( OOod <br /> CURRENT L AL AOE CT fACILITY ID• APPROVED BY NAME PHONE#WITH AREA CODE ` <br /> IxEPMR NUMBER PERMIT APPROVAL GATE PERMIT EXPIRATION GATE ^410 <br /> LOCATION CODE CENSUS TRACT N F <br /> SUPERVISOR-DISTRICT CODE BUSINESS PLAIN DATE ED �\"J <br /> D 3, a` YES NO <br /> CHECK# PERMIT AMOUNT' SURCHARGE AMOUNT FEE CODE RECEIPT Ar BY: "\.y <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPUCATION(S), UNLESS THIS IS A CHANGE OF SITE INFOON ONLY. <br /> CFORM A(3-2-88) I � J_ <br /> / DATA PROCESSING COPY 5 <br /> rc3��`� z3 �a <br />