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OF' <br /> f Z�P`au.iti'T�\ <br /> STATE OF CALIFORNhK WATER RESOURCES CONTROeBOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `°`. <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 ERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 10 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE AME �Q CARE OF QRESS INFORMATION <br /> rV <br /> ADDRESS ' ARES CROSS STREET ✓Boxwmute ❑ PAWNERSHIP ❑ S+AFE-AGENIX <br /> �l / k �1 s .y^' ❑ IND DRALUk- ❑ LOCAL AGENCY F F11AL A ENCI CO <br /> hL// GiN 'V ❑ INONIDCAL ❑ COUNNAGENCY ,A <br /> CITY NAMEI L, <br /> STATE ZIP CCE I SITE � E p,WITH AREA CODE <br /> ife; CA <br /> TYPE OF BUSINESS 2 p IBUTOP 4 PROCESSOR ✓Bax if INDIAN EPA ID # #of TANK's <br /> ❑ t GAS STATION ❑ 3 FARM ❑ 5 OTHER RRUSTYATNDS or ❑ AT THIS SITE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCt CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME( T,FIRST) PHQWE I TH AREA CODE DAYS. N E(AST,FIRST) PHONF TH AREA CODE <br /> NIGHTS. NAME(LAST,FIRST) PH`NE WITH AREA CODE NIGHTS ME(LAST,FIRST) PHONED,WITH AREA CODE <br /> SIAP T <br /> II. PROPERTY WNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING. STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAM / CARE OF ADDRESS INFORMATION <br /> MAILINGfor STREET ADDRESS(/^✓,V ✓Bax to Intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ❑ it. ❑ 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# JURISDICTION# AGENCY# FACILITY ID It It of TANKS at SITE <br /> rn10 p o p © L a <br /> CURRENT LTOCAL AGENCY F CILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> �° STE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVIS R-DISTRICT CODE BUSINESS PLAN FILED DAT FIL op <br /> YES NO Q O <br /> CNE # PERMITAM UNT SDRC R E AWOUNT FEE CODE RECEIPT# Y: <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 INFORMATIO LY. <br /> FORM A(3-2-88) <br /> law DATA PROCESSING COPY �►' <br />