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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> SE�� .SAF <br /> 4� <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> G <br /> COMPLETE THIS FORM FOR EACH FAC TY/SITE <br /> MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWAL PERMIT 2<CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ] <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) I C <br /> FACILITY/SITE NAME CARE OF ADDRESS RMATION <br /> ZLY <br /> ADDRESS NEAREST CRO?ss STREET ✓ sommw ❑ PIARXRSHIP ❑ STATAGE1VLY N <br /> 0 NEWD AL ❑ DOCAL OUNTY-AGEN ❑ eomuACDw � <br /> ❑ INDMWAI ❑ COUNTY-AGENCY <br /> CITY NAME STATEZIP CODE SITE PH NE p,WITH AREA CODE <br /> CA 46� 7 - 7110 <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR I10CESSOR '/Box if INDIAN EPA ID p <br /> RESEk of TAMC* <br /> ❑ I GAS3TATION ❑ 3 FARM ❑5 OTHER TRUSTLANDS <br /> ATION or ❑ NQy1,� I AT THIS SITE / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S-.tt n.ur-e, /L,tyl-el <br /> NIGHTS: NAME(LAST FI ST) 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 /> A,7,1 Pew eom fhvY <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP 0 STATE-AGENCY <br /> L!./!/ ❑ CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY <br /> T4 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE _ ZIP CODE PHONE N.WITH AREA CODE /!�J <br /> Ic <br /> rJi� SGS>3 <br /> 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE DECODE PHONE#,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. ❑ IL III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION R AGENCY R FACILITY ID# It of TANKS at SITE <br /> loblll= lololol ) l <br /> CURRENT LOCAL AGENCY FACILITY ID If APPROVED BT NAME PHONE It WITH AREA CODE <br /> 0 N /iV/ N/1 <br /> PERMIT NUM ER PERMIT APPROVAL <br /> DA PERMIT EXPIRATION DATE <br /> LOCATION CODE I CENSUS TRACT Y SUPE SOR•DISTRICT CODE BUSINESS PLAN FILED DATEFILE <br /> YES [:] NO 7 1J`' <br /> CHECK# PERMIT 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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY w <br />