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STATE OF CALIFORNIX WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND 4TORAGE TANK PROGRAM =" <br /> SITE (f,,FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION w <br /> COMPLETE THIS FORM FOR EACH FACT /SITE `"�•oe�`" 1 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMAN OSEDSITE N <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) A <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Bur�lnkele 0 PARTNERSHIP ❑ STATE AGDO <br /> c CORPOPATCN 0 =k AGDO 0 FEDERAL AGDO <br /> G 0 INDNIDWL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> cic CA 9S�S ave-vb _ s� <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 P SSOR ✓Box VATION if INDIAm N EPA ID # <br /> ❑ t GAS STATION ❑3 FARM RESEROTHER TRUST LANDS E1 #of TANK'# <br /> 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 /> 6ole</r - -3(Pon Sa oue <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE q WITH AREA CODE � <br /> SR ._P— SR 414-4 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> C9o�IC(/i Tom-! lC � <br /> MAILING or STREET ADDRESS ✓ oindicete O PARTNERSHIP 1:1 STATE-AGENCY <br /> CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> SR 0AP tcs 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME T STATE ZIP CODE PHONE#,WITH AREA CODE <br /> .5-,t ^-,e4S r[.. — <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓aafto <br /> indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE 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. II. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# If of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# / APPROVED BY NAME PHONE#WITH AREA CODE <br /> // <br /> PER NUMBER PERAPPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS 711ACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED'/^� /rc� <br /> 3� 3 3 YES [] NO Lo L v <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST 111 OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-S&) <br /> DATA PROCESSING COPY <br />