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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> ICOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F-1 I NEW PERMIT F_�3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE <br /> C.n <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE cn <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FA��a'A��F"�rrj CARE OF ADDRESS INFORMATION <br /> 'je <br /> A6DRESS NEAREST CROSS STREET V Bm 10,niicale 11 PARTNERSHIP Q STATE AGEICY <br /> 0 CORPOMflON 11 LOCAL-ACRIO 0 FUVLAOM <br /> 0 WMADUAL 0 OOUNTY-AGENCt <br /> CITY STATE SITE PRO E P,WITH AREA CODE <br /> C5-1 CA 7� <br /> TYPE OF BUSINESS F 12 DISTRIBUTOR PROCESSOR I VSox 0 INDIAN EPA ID N If of TANK's <br /> 1 GAS STATION YT 3 FARM 5 OTHER RESERVATION or �AT THIS SITE <br /> I TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS. NAME(I-AST,FIRST) PHONE#WITH AREA CODE DAYS NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST FIRST) PHONE#WITH AREA CODE NIGHTS NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING.STREET ADDRESS -/Box to Indicate 0 PARTNERSHIP El STATE-AGENrY <br /> El CORPORATION El LOCAL-AGENCY El FEDERAL-AGENCY <br /> 11 INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE I ZIPCODE HONE N,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS V Do.to indicate D PARTNERSHIP 0 STATE-AGENCY <br /> [I CORPORATION Cl LOCAL-AGENCY 1:1 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. [:] it. [_–] Ill. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUEAND CORRECT <br /> IAPPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID 0 #of TANKS at SITE <br /> I I I :� lc;� I �1 IZ7 1 1 1 10 <br /> C RENT LOCAL A ENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> q9 I <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATT�DE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DAM IR ED <br /> YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT If BY: <br /> If <br /> THIS FORM MUST BE ACCONNIAN IED BI AT LEAST'I,OR MOI E TANK PERMIT F 0 R M 'B'APPLICATION1 SI, UNLESS TH 11 IS A CHANG E OF SITE I NFORMATION 0 N Ll <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />