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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> qe�� 7tiF <br /> d <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SI7E <br /> ONE ITEM ❑2 INTERIMPERMIT ❑ 4 AMENDEDPERMIT 6 TEMPORARY SITE CLOSURE 3/ <br /> i0 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILTV/SITE NAME CARE OF ADDRESS INFORMATION <br /> . Flr o ell i Truck ' <br /> ADDRESS NEAREST CROSS STREET 0 CORPORATION ❑ LOCALAGENCY ❑ FEDBUI.ACENCY �1 <br /> v a'�T C• n ❑ M MWAL ❑ WUNTY.AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE LSA <br /> A <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR F-14 PROCESSOR ✓Box if INDIAN EPA ID Na of TANK's <br /> ❑ I GASSTATION ❑ 3 FARM ❑5 OTHER TRUSTYLANDS VATION or ❑ AT THIS SITE kX <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS'. NAME(IAST.FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> I <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME $TATE ZIP CODE PHONE If,WITH AREA CODE <br /> I <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 11PARTNERSHIP 13STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 111.❑ <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# CILITY ID# #of TANKS at SITE <br /> 7 6 0 0 0 0 <br /> 1PERMI:: E:1l <br /> U LO ALLAAGFNCCYYY FACILITY IDN APPROVE — PHONE N WITH AREA CODE <br /> ,-IIJJ.•.•.• L MIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO / <br /> CHECK# PERMIT AMOUNT SURCHARGEAMOUNT FEE CODE RECEIPTS 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(3-2-88I - <br /> G "`� DATA PROCESSING COPY `.� <br />