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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': r' <br /> UNDERGROUND STORAGE TANK PROGRAM = ' ) <br /> Sl CILITY/SITE, INFORMATION and/or PERMIT APPLICATIONP<. <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MAR ONLY ❑ T NEW PERMIT 3 RENEWALPERMIT 6 CHANGE OF INFORMATION 7 PERMANENTLYCLOSEO SITE <br /> ONE ITEM El 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME p CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓itakinneW 0 PABTNERGIP 0 STATE AGENCY N <br /> ❑ DXPOR IGH 0 U)SkLAGENO' 0 FEDEMLAGENCI co <br /> Cl0 L4 INDIMDIN 0 COATY AGENaco <br /> CITY NAMES� / I STATE ZIP ODE SITE PHONE N.WITH AREA CODE �I <br /> CA <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 Pfl ESSOR ✓Box if INDIAN EPA 10 N <br /> RESERVATION or M of TANK'S F1 <br /> 1 GASSTATION 3 FARM rr,,OTHER TRUST LANDS u AT THIS SITE L� <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAME(UST,FIRST) (o P ONE N WITH AREA CODE DAYS' NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 6OOL_ It <br /> NIGHTS: NAME(LA ,FIRST) VIFIONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME p CARE OF ADDRESS INFORMATION <br /> C <br /> MAILING of STREETRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> / ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STA], ZIPCODE � jiONE IF IFWITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING of STREET ADDRESS ✓Box loindlcale 0 PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION 0 LOCALAGENCY0 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. E] if. 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) DAU` <br /> F <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION N AGENCY R FACT If of TANKS at SITE <br /> CURRENT LOC CY FACILITY ID/NI APPROVED BY NAME PHONE N WITH AREA CODE <br /> i, In AL 1 ( Le <br /> PERMIT NUMBS PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACjPSUPEROSTRI BUSINESYPIAN❑FILED ❑ OATS FIVD <br /> NO <br /> ES <br /> CHECKN� <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N O`CT BY: 7 <br /> \ THIS FO M� JIUS E ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY <br /> \\W\I <br /> FORM%h3-2 <br /> DATA PROCESSING COPY <br />