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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': k <br /> UNDERGROUND STORAGE TANK PROGRAM u <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F ILITT/SITE rA <br /> C9�ia PHP <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT IV CHANGE OF INFORMATION ❑ 7LY CLO TE I"a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE —4] -4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) CN <br /> FACIUTY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Box kinGrak 0 PARTNERSHIP 0 FATE AGENCY <br /> ❑ 0MRATION 0 LWAAGENCY ❑ FEDERAL AGENCY <br /> 0 INDmWAL 0 CWNW.AGENCY <br /> CITY NAME STATE ZIP CODE �� SITE PHONE N,WITH AREA CODE <br /> "-T CA <br /> TYPE OF BUSINESS: n 2 WRIBUTOR ❑ 4 PROCESSOR ✓B if INDIAN EPA ID M <br /> L�,�-�',/ RESERVATION or N of TANK'F <br /> ❑ I GASSTATION 3 FARM ❑ 5OTHER TRUST LANDS ❑ ATTHISSITE <br /> EMERGENCY <br /> $CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LA T,FIRST) PHONE 9 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> / U �C <br /> NIGHTS: NAME <br /> ST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME 5C CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE 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. Ir it. ❑ Ill. ❑ <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 R JURISDICTION If AGENCY# FACILITY ID N S of TANKS at SITE <br /> o 01 z/1 / I(r,79 <br /> CURRENT LOCAL AGENC F ILI I .Y APPROVED BY NAME PHONE a WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT X SUPERVISOR•DISTRIC CODE BUSINESS PLAN FILED DATE FILED <br /> Z 3 YES ❑ NO ❑ 6�� <br /> CHECK 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 /> '10.1 DATA PROCESSING COPY <br />