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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 1A% UNDERGROUND STORAGE TANK PROGRAM ma <br /> SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m to <br /> lJ COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT Eer, CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE r <br /> I <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> ' FACILITY/SITE NAMEM. CARE OF ADDRESS INFORMATION <br /> - <br /> ADDRESS NE REST CROSS STREET ✓BAnb idince ❑ PARTNERSHIP ❑ SfATEAGENCI <br /> ❑ NON ❑ LOCAL AGENCY ❑ FEDERAL AGRICY <br /> L CLE I JAL ❑ CGAm-AGBICY <br /> CITY NAME STATE ZIP CODE / SITE PHONE Jr.WITH AREA CODE <br /> CA �'52o�t _� 1 . <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 POQESSOR ✓Box it INDIAN EPA ID a <br /> #of TANK'L <br /> RESERVATION or <br /> ❑ 1 GAS STATION ❑ 3 FARM 60THEfl TRUST LANDS ❑ ATTHISSITE / <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 /> D9 2ZZ <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHI51NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> C_ <br /> H. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING or STREET ADDRESS Be.✓ to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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. f❑ 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 M JURISDICTION N AGENCY# FACILITY ID K #of TANKS at SITE <br /> o J <br /> CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE N WITH AREA CODE <br /> 3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED <br /> C70, g res No <br /> CXECKN PERMIT AMOUNT SURCMRGE AMOUNT FEE CODE RECEIPT# 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(3-2418) - - — <br /> \.a DATA PROCESSING COPY �,�/ <br />