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... .. .:.. .:. .. cTy._,.�zv.e• V.,,�.:"91BRiT^"IFStF+>lµT�j`�',`"' ,.t'�I`...- . . ,.�... ,:;� .H,� <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> U: <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F41 NEW PERMIT 3 RENEWRL PERMIT ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> BO <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS I' NEAREST CROSS STREET g��ldXrW L] PARTNERSHIP ❑ SfATE AGENCY <br /> LYLUA"NATIM ❑ LOCALAGENGY ❑ FEDERAL AGENCY 0000 <br /> ST ❑ Ixorviou ❑ cox acBNOY <br /> CITY NAME STATE ZIP CODE TE PHONE x,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR I I/BOX if INDIAN EPA ID a <br /> RESERVATION or a of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM [�Rol TRUST LANDS ❑ AT THIS SITE <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 /> r7p-rruio s'ro <br /> NIGHTS NAME(LAST,FIRS PHONE#WITH AREA CODE NIGHTS NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ZaT7�br-0ZS- <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> T '—` <br /> MAILING or STREET ADDRESS ✓BOX to iodicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY 13FEDERAL-AGENCY <br /> ❑ INDIVIOGAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S t <br /> MAILING or STREET ADDRESS ✓BOX to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUALS ❑-COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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. II. ❑ 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 If AGENCY b FACILITY ID If If of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY 10 II APPR VED BY NAME 1,19 PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERM P ATION'OATE <br /> LOCATION CQPE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Z3. E3 O `�� - �--- �- en <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODERECEIPT F B <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(3-2-BB) <br /> DATA PROCESSING COPY —� <br />