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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM IA': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH AGILITY/SITE `"'•�^"" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EV5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓6aabidi ❑ PARTNERSHIP ❑ STATE AGENO <br /> G ❑ CUWWATIIXI O LGCV-AGENCY ❑ FEGERA GENCY <br /> -� 1�:. l ❑ INOIYIWAL 0 COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> r� CA �— C� <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ A PROCESSOR ✓Box i}IION or F of TANK'F <br /> NDIAN EPA ID It <br /> ❑ 1 GAB STARON ❑ RESERVAT3 FARM 5 OTHER 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 �.,��A., // + � CARE OF RESS INFORMATION � <br /> ti:r .o AVL 1P'' h+ opCC , ' <br /> MAILING or STREET ADDRESS ✓Box to mde,ale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> /�- Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 02yC 1 <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS -/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCALAGENCYD FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE 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. ❑ it. v 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 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* JURISDICTION M AGENCY R FACILITY ID B R of TANKS at SITE <br /> c4; <br /> CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA N CODE CENBUB TMCT F fYPERVIBOR-DISTRICT GODS BUfINE88 PLAN FILED DATE FILECL <br /> YES NO ❑ <br /> \ CHECKF PERYR AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT♦ 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 ONLY. — <br /> FORM A(3-22 88B)_ cJ <br /> +-\T <br />