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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD s°'ccs` <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �S4f ORi,P <br /> FMARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F'a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE AD 00 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) QO <br /> FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION <br /> � UC7 Gr pro C <br /> ADDRESS NEAREST CROSS STREET ✓8mbi0iaM C PARTNERSHIP C STATE AGENCY <br /> C CORPORATION C LOCAL AGENCY C FEGAAL-AGENCY <br /> �a �` `• W7•'�'� ❑ INOIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> .F CA gS�os <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 <br /> ESSR INDIAN EPA ID 4f ION or❑ 3OTHER <br /> RESERV .1 TANKs <br /> THISSITE <br /> LANDS El AT / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Zarr K /!1�(v v u S 1 <br /> NIGHTS: NAME(LA T.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODEi, <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATI fJ• <br /> ny�ll C 4flu <br /> MAILING or STREET ADDRESS ✓ to indicate <br /> C PARTNERSHIP C STATE-AGENCY <br /> (/ CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> O INDIVIDUAL O COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODEP HONE N,WITH AREA CODE <br /> 0 <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓0660 indicate C PARTNERSHIP C STATE-AGENCY <br /> CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> C INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME $TATE ZIP CODE PHONE N,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. Tl� 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 M JURISDICTION K AGENCY M FACILITY <br /> (IIDD M p M of TANKS at SITE <br /> L? p Q O o <br /> CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE N WITH AREA CODE <br /> G <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> © 3PV I YES ❑ NO ❑ - <br /> �- <br /> CHECK X PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: <br /> TiHIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION <br /> ,- M //q/M A(�2-881 <br /> V <br /> A„� DATA PROCESSING COPY �, <br />