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... r., ..... <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM _ <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , <br /> /_�I COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT Ef5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ <AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE S <br /> 10 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> y <br /> ADDRESS J ^ ^� NEAREST GROSS STREET ✓Bmm ATIQ ❑ YLWNEREN ❑ STATE AGENENCYCY LD <br /> ,tet e T(I ❑ coavoxMwN Cl LacuACENcr ❑ 1 IacENcr W <br /> ❑ iNOiVIW11 0 OIMRAGEHLY N <br /> CITY NAMESTATE �gDE SITE PHONE N.WITH AREA CODE <br /> � ", CA ZIPysa <br /> TYPE OF BUSINESS ❑ p DISTRIBUTOR ❑d PROCESSOR ✓Box it INDIAN EPA ID x N of TANK's <br /> ❑ ATION <br /> 1 GAS STATION ❑ :FARM ❑ 5 OTHER TRUSESETVLANDS or ❑ 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 N WITH AREA CODE <br /> NIGLITSS. NAME(LAST FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> 1l////r <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME JARF OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESSBo rdicme 0 PARTNERSHIP 0 STATE-AGENCY <br /> RATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ✓ <br /> i INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP DE_ 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 V ✓Box to md"t. 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 M,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. 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 /> COUNTYII JURISDICTION k AGENCY A FACILITY ID R A of TANKS At SITE <br /> oot� oa � aoao <br /> CURRENT LOCAL A ENCY FACILITY ID N� APPROVED BY NAME PHONE A WITH AREA CODE <br /> Itfn <br /> F.Rq <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSU TMCT SUPERVISOR-DISTR T COPE BUSINESS PLAN FILED DATE !D p <br /> Q / r¢s ❑ Ho ❑ /7 �0 <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT• BY: <br /> THIS FORM MUST BE ACCOMPANIED BY ATLEAf OR MORE TANK PERMIT FORM'B''APPLICATION(4 II' STHMISACNANGEoFSREINFoRmA noN. NLY. / <br /> v low <br />