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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM .A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION 7 P TLY CL ED SITE N <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE ry' <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) Fw� <br /> FACILITY/SITE NAME o LI TR�cklti CARE OF ADDRESS INFORMATION <br /> A . <br /> ADDRESS _ I I NEAREST CROSS STREET ✓Baxpese ❑ PARINEIRIP ❑ STATE AGENCY <br /> L- CT�A)N - S I. °o IAR OUiON ❑ AG NC 11 RD AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: F-12 DISTRIBUTOR –]d PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ ❑ ❑ TRUSTILANDS ESERVATION or ❑ AT <br /> If T THIS T D <br /> 1 GAS STATION 3 FARM S OTHER ATTHIS TE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) _ - <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(I-AST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> i <br /> MAILING.STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Ili. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING o,STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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. ❑ If. ❑ 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 R JURISDICTION N AGENCYIN FACILITY ID N R of TANKS at SITE <br /> v QTa <br /> CURRENT LOCAL AO NCY FACILITY ID# APPROVED BY NAME PHONE If WITH AREA COD <br /> TELI <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATEFILED <br /> YES [:] NO ❑ 1 r 0 <br /> JRMHECK k PERMITAMOUNT SURCNAROE AMOUNT FEE CODE RECEIPT M Y: <br /> HISFORMMUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> A(3-2-SBI "- <br /> `r DATA PROCESSING COPY N,.I` 5 <br />