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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> w�� aLm <br /> SITE ' FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> .� o <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 46 <br /> / <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SIT NAME -fes CAREOFA RESSINFORMATION <br /> 14m <br /> ADDRESS ' G /� NEAREST CROSS STREET ✓Itwo,,dow 0 PARTNERSHIP 0 STATE-AGENCY <br /> 2-4 �—O 2 J D INDIVD� ❑ �Y�OffA-AGENCY ❑ FEDERAL AGER <br /> CITY NAME STATE ZIP CODE SITE PHONE M.WITH AREA CODE <br /> rj CA <br /> TYPE OF BUSINESS: ❑ 2DISTRIBUTOR ❑4PROCESSOR I ✓Box if INDIAN EPA IF <br /> N of TANK'S <br /> RESERVATION or <br /> ❑ 1 GAS STATION ❑3 FARM ❑ S OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION . <br /> v <br /> MAILING or STREET ADDRESS ✓Bos to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0. rx Sy7 DCORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME C ( STATE CODEPHONE N.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME QQ CARE OF ADDRESS INFORMATION <br /> GS <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE HONE#.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: 1. ❑ II. Ey 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 p JURISDICTION N AGENCY N FACILITY ID P #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID X APPROVED BY NAME PHONE a WITH AREA CODE <br /> 2— <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSU�TMCTa' SUPERVISOR-DISTRICT CODE BUSINESS PLAN O D HD ❑ T%FILED <br /> YES <br /> CHECK X PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT It 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 ONLY. <br /> FORM A(3-2-88) <br /> \ A \ —00 — DATA PROCESSING COPY <br /> \VnA "1 <br />