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1j <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> Asa <br /> 4 <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE —1 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° <br /> �. COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT L215 CHANGE OF INFORMATION ❑ 7 PEftlMlithilii CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 10 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME () . ' CAREOFAD RESSINFORMATION <br /> /CIS a. ✓� A. <br /> rV <br /> ADDRESS NEAREST CROSS STREET ✓8oaolr rxi ❑ PAAfNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION Cl LOCAL AGENCY FEDERALAGM <br /> Ao 14J054 Cl INDIVIDUAL ❑ COUNTY AGENCY <br /> SII CITYNfjWE ,— `m STATE ZIP CODE SITE PHO A.WITH A EA CODE W II <br /> � fur y� CA .S� Z Q`I -f <br /> TYPE OF BUSINESS EPA ID N <br /> ❑2 DISTRIBUTOR ❑ d PROCESSOR RESERVATION or #of TANK's <br /> ❑ I GASSTATION ❑3 FARM �5 <br /> OTHER TRUST LANDS ❑ AT THIS SITE G <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME( SL FIRST) / PHONE k WITH AREA CODE DAYS: N E(LAST,FIRST) PHONE# ITH AREA CODE <br /> l r Z <br /> ISI NIGHTS. NAM (LAST.FIRST) PHO# p WITH AREA CODE NIGHTS'. AME(LAST,FIRST) PHO# # I AREA CODE <br /> S S � s j <br /> If. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME .. CARE <br /> ,OF/A D�^R 1ESS INFORMATION <br /> MAILING STRE DRE S ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION E) <br /> CORPORATIONDERAL-AGENCY <br /> 11INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NA —1 LSTATE ZIP ONE MITH AREA <br /> CqS <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OFA DRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCYi <br /> 1 V ❑ CORPORATION ❑ LOCAL-AGENCY ❑ DERAL- ENCY 'I <br /> El INDIVIDUAL 11COUNTY-AGENCY <br /> CITY NAME I I I STATESZIP CODE PHONE AREA CODE <br /> PL J <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE 11)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 /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> i <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION k AGENCY# FACILITY ID R R o/TANKS at SITE <br /> C� oa I= 1010101 / <br /> CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE M WITH AREA CODE <br /> �C) <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> I <br /> LCHECK# <br /> ODE CENSUS TRACT k SUPERVIS DISTRICT CODE BUSINESS PUN FILED D FIT. D � <br /> C YES ❑ NO <br /> PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> k <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 ONL)!r+ <br /> l FORM A(3-2-88) J\ <br /> DATA PROCESSING COPY `„( <br />