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STATE OF CALIFORNIA <br /> FORM 'A': WATER RESOURCES CONTROL BOARD ° r; <br /> � <br /> SITE UNDERGROUND STORAGE TANK PROGRAM <br /> FACILITY/SITE, <br /> Y/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �,�, �"�', sa <br /> MONS ITEARKOONLY 1 NEW PERMIT 1:13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION <br /> ❑ 2 INTERIM PERMIT E]1:1 <br /> AMENDED PERMIT 7 PERMA SED SITE IV <br /> ❑ 6 TEMPORARY SITE CLOSURE /1 Im <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) V <br /> FACILITY/SITE NAME N <br /> CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Boe to YNx21A ❑ PAIUNERSHIP ❑ STATE AGENCY <br /> r �I onw ❑ COROAAiION ❑ LOCAL AGENCY ❑ FEDUALAGEND' <br /> E03INOMDUAL 13COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE f,WITH AREA CODE <br /> CA r1r�l y D <br /> TYPE OF BUSINESS' ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA 10 # <br /> ❑ 1 GAS STATION ❑' 3 FARM 5 OTHER RESERVATION ora of TANK's <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE IT WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE R WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> I <br /> MAILING or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. II. ❑ 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 A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID At #of TANKS at SITE <br /> m �] I ooa K= 000 101 <br /> CURRENT LOCAL AGENCY FACILITY ID#I APPROVED BY NAME PHONE#WITH AREA CODE <br /> Z <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FI LED DATE FILED <br /> �\ YES NO ❑ r� / <br /> \ CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: /ti <br /> 1fk <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST" OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UMFSSTHIS IS A CHANGE OF SITE INFORMATION ONI/Y. <br /> FORM A(3-2-88) V/ <br /> VV\ A-%.e DATA PROCESSING COPY �^ J <br />