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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD /s` ' '"e <br /> FORM `A': '• a <br /> UNDERGROUND STORAGE TANK PROGRAM l " <br /> SITE A FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONCL) :: <br /> (,� COMPLETE THIS FORM FOR EACH FACILITY/SITE °'Anon��^ <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANEN7LYCLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE J? �' <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) I <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION cyp <br /> ADDRESS vf NEAREST CROSS STREET ✓BwbiMraN D PARMERSHIP ENCY D STATE-AGn <br /> 1*7 <br /> ,?Ys Off. ❑ D3R9RATICN D LOCALAGD0 D FEUSVL-AGFNCY 0M0 <br /> G1�ABNOUAI D WUNI!#IENCY W <br /> CITY NAME STATE ZIP CODE TE PHONE a.WITH AREA CODE N <br /> CA 933 a-3q1 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑4 PROCESSOR ✓BOX R INDIAN EPA ID N <br /> ❑ I GASSTATION ❑3 FARM �6THER TRURESSTLANDS or ❑ O A-1'V AT THIS SITE l <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FW) PH E N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) ONE ITH AREA CODE NIGHTS: NAME(LAST,FIRST PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMgyI ON <br /> MAILING or STREET ADDRESS v ✓BOA to' oicete D PARTNERSHIP D STATE-AGENCY <br /> /( ❑ C ORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY <br /> /�3 DIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M,WITH AREA CODE <br /> e/in�m1� 4 OcYp_ <br /> Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME �-- n // • / ,{..,,,� , CARE OF ADDRESS INFORM/ <br /> MAILING or STREET ADDRESS ✓Box to intlicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL OCOUNTY-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. ❑ II. IS.❑ <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 R AGENCY N FACILITY ID N R of TANKS at SITE <br /> Gl 0 10 U U0 1c) 10 1I <br /> CURRENT 1.7O/l C/TID M APPROVED BY NE PHONE 9 WITH AREA CODE <br /> /s <br /> PERMIT NUMBER PERMIT APPROVAL DATE^K' MITEXPIRATIO <br /> X7/11 <br /> N <br /> LOCATON CODE CENSUS TRACT N SUPERVI OR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 1 ?3Pa YES [-] NO <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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(3-2-88J <br /> �. DATA PROCESSING COPY <br />