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iw <br /> STATE OF CALIFORNIA <br /> FORM 'A': WATER RESOURCES CONTROL BOARD <br /> 5"��ox• ty <br /> SITE UNDERGROUND STORAGE TANK PROGRAM ' <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION u i <br /> COMPLETE THIS FORM F <br /> MARK ONLY ❑ 1 NEW PERMIT OR EACH FACILITY/SITE to <br /> ONE ITEM ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION <br /> ❑2 INTERIM PERMIT ❑q AMENDED PERMIT <br /> I. FACILITY/SITE INFORMATION &ADDRESS - 6 TEMP ORARYSITE CLOSURE <br /> / PER SEDS i-► <br /> (MUST BE COMPLETED) v <br /> FACILITY/SITE NAME / F-► <br /> / ' 1 <br /> CARE OF ADDRESS INFORMATION 1 F� `o co <br /> ADDRESS U/V 6- <br /> (ti NE AR EST CROSS STREET <br /> CITY NAME ✓COxbiMn ❑ LOCAL <br /> ❑ STATEAGBI <br /> � /'� COIVID A( N ❑ LOCAL AGENCY ❑ FEDERAL AGENC/ <br /> L.o io I STATE INDNDUAL ❑ COUNIY.AGENCY <br /> ZIP CODE SITE PHONE#, <br /> TYPE OF BUSINESS: ❑4 DISTRIBUTOR ❑q PROCESSOR Box if INDIAN EPA ID# WITH AREA CODE <br /> El GASA <br /> 1 STATION ❑3 FARM ❑5 OTHER RESERVATION., ❑ - <br /> TRUST LANDSIf of <br /> EMERGENCY CONTACT PERSON(PRIMARY) AT THIS STTHIS SITE <br /> DAYS: NAME(LAST,FIRST) EMERGENCY CONTACT PERSON(SECONDgpy) <br /> PHONE#WITH AREA CODE <br /> C �'�/ DAYS: NAME(LAST.FIRST) <br /> NIGHTS: N ` J L'0-2 <br /> / PHONE N WITH AREA CODE <br /> LAST,FIR57) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE M WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME <br /> f CARE OF ADDRESS INFORMATION <br /> MAILING m STREET ADDRESS O <br /> A/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE <br /> PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FNAMECARE OF ADDRESS INFORMATION <br /> REET ADDRESS Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 13 INDIVIDUAL ❑ COUNTY-AGENCY <br /> 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. ❑ It. ❑ IN.❑ <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 R JURISDICTION R AGENCY k FACILI If of TANKS at SITE <br /> l <br /> CURRENT LOCAL AGENCY FACILI If APPROVED BY NA PHONE N WITH AREA CODE <br /> 1 D(\ G <br /> PERMIT NUMBER PERMIT EXPIRATION DATE <br /> LOCATIOB.�O CENSUS TRACT♦ SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED D FILED <br /> [-�Ij 23 K) El� NO El <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: <br /> ITHIS 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 /> 1 FORM A(3-2-88) J <br /> V\VI <br /> 0'.o 1 DATA PROCESSING COPY '"'►t <br />