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h, <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM �* Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> Ic <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE N <br /> cn <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ C AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 3 cn <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) O <br /> FACILDY/SITE NAME CARE OF ADDRESS INFORMATION N <br /> ADDRESS ' <br /> NrEA/REST CROSS STREET ✓ tom ❑ PA,RRyEWIP ❑ STATEAIIENC/ <br /> E` UL1( >J ❑ �VOUT10N' ❑ EocuAGDO ❑ F RA.-AGIND <br /> ❑ Naw(>UAL ❑ WUNW-AGENC <br /> CITY NAME _ STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> _Tl ca sly _% - .�2✓y <br /> TYPE OF BUSINESS: 2 DISTRIBUTOfl ❑ A PROCESSOR ✓RESBox ii INDIAN EPA ID a <br /> 1 GAS STATION ❑ 3FARM ❑ 5OTHER TRUST TION or ❑ If of TANK'R - <br /> ATTHISSITE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE R WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 04 6` �6Y6J ( S Nei I zcn - 7 d2 0 <br /> NIGHTS: NAME�(LAST,FIRST) HONE#WITH AREA CODE NIGHTS: AME( T,FIRST) PHONE#WITH AREA CODE <br /> I Wct - O <br /> II. PRO ERT OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> e a__fir <br /> MAILING or STREEt ADDRESS ✓8ox Io indicate 11PARTNERSHIP 11STATE-AGENCY <br /> E/ ElCORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE 'ii :r DE PHONE N.WITH AREA CODE <br /> N CA I VSZ.Z-'7 <br /> III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME / CARE OF ADDRESS INFORMATION <br /> S CPL�frr1( S 6 L�1 <br /> MAILING or STREET jDDRESS ✓ ox to ndicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> R�1•/ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> a� 1 I ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY STATE CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS SZ <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ III.ig <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 A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY W JURISDICTION Al AGENCY a FACILITY ID a If of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID R APPROVED BY NAME PHONE N WITH AREA CODE <br /> C e;-"TR I <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT R SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO ilkl2gIn <br /> CHEC R PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT R 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 NLY. <br /> FORM A(3-2-M) <br /> ,�, DATA PROCESSING COPY �"�;4 <br />