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. r..x.m" .r^FMRi'A"'a:•.�;rpNxSVsq...r .-Y•v.—.. .�.. _ .. -... <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': V <br /> UNDERGROUND STORAGE TANK PROGRAM =" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> F;ARK,ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITEONE TEM ❑2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE V; <br /> V <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) Cfl <br /> FACILITY/SITE NAME CARE OFADDRESS INFORMATION <br /> 1 djo k Me Ne <br /> DRES`S��II♦� �. NEAREST CROSS STREET ✓Bm IoWM ❑ PARTNERSHIP ❑ STATE AGENCY <br /> `" GL ❑Cl ORRINDIVIDAION ❑ LOX <br /> AGENNC ❑ FEDERAL AGENCY <br /> IL' TY NAME �1 N STAT``A 215366 - <br /> SITE PHONE#,WITH AREA CODE <br /> ,l TYPE OF BUSINESS: F-1 2 DISTRIBUTOR F-1/PROCESSOR ✓Box if INDIAN EPA ID # <br /> IS <br /> RESERVATION or AT THIS 817E <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑5 OTHER TRUST LANDS <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 /> A, z PHONE p W!72-3 <br /> NIGHTS: NAME(LAST.FIRST) ITH 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 /> Sime 05 ::c <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 It.WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME A CARE OF ADDRESS INFORMATION <br /> 454f3'w a; <br /> MAILING or STREET ADDRFSS ✓Box to indicate ❑ PARTNERSHIP El STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> _ ❑ INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATF ZIP CODE PHONE N;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. ❑ I. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 11E I I I ;Zz Z I I lz <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> �2rP��r <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE <br /> 2-3. go 3 za I YES E] NO 0 I <br /> \ CHECK# PERMIT AMOUNT SURCHARGE AMOUNT 7 <br /> EE CODE RECEIPT# BY: <br /> �- z_L_ I / <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 /> V., l FORM A(3-2-88) <br /> \\ �- 'Z- DATA PROCESSING COPY / <br />