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STATE OF CALIFORNIA' WATER RESOURCES CONTROL BOARD <br /> W <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE �� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE "'•�""�" �� <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) Oe <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 1;?;;6e Diiu <br /> ADDRESS NEAREST CROSS STREET ✓Swordore ❑ PMTNOISP ❑ STATE-AMCY <br /> o'6 E. i h r B ❑ D)WRATON 11IOCk AGEi1L1 13OERALK-80 <br /> cp �C. ❑ INDIVIDUAL ❑ CIM 41Y.Aiii <br /> CITY NAME STATE ZIP CODESITE PHONE$1.WITH AREA CODE <br /> es / CA r5_3110 <br /> 'r 4, -a vtO <br /> TYPE OF BUSINESS: ❑ 2 D Ofl ❑4 PROCESSOR -/Box if INDIAN EPA ID # It IH TANKY <br /> RESERVATION or AT TNIS SITE n <br /> ❑ 1 GAS STATION 3 FARM ❑5 OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It 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#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ��y�p u 5 S <br /> MAILING or STREET ADDRESS �✓Byx to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 11 ORPORATIOA ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> FFdd INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE R,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> s4tryLa <br /> MAILING or STREET ADDRESS ✓Bo indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ PORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> DIVIDUAL ❑ COUNTY-AGENCY <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 FON 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 /> I <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION# AGENCY# R b of TANKS at SITE <br /> 3 a 3 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY PHONE N WITH AREA CODE <br /> Eou <br /> PERMIT NUMBER `PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> O 3a�-- 3c -CP YES NO <br /> CH <br /> PERMIT AMOUNT SURCHARGEAMOUNT FEE CODE RECEIPT# BY: a�AU <br /> C <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> �� ) „y DATA PROCESSING COPY <br />