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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD toF <br /> SST t���k,�•THP <br /> tee. -'•, <br /> FORM 'A': T <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r <br /> �o <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE CR Ro RN1P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 ffaAANiNTLY CLOSED SITE � <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE -4 <br /> 0 <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) 0 <br /> FACILITY/SITE NAME rCARE OF ADDRESS INFORMATION <br /> V r,,-r eg_ L Lv N <br /> -I�'V z <br /> ADDRESS NEAREST CROSS STREET to ndirate ❑ FAATNERSHIP ❑ STATE-AGENCY <br /> /h .5 A` . �F-/� COFIPORATION ❑ CCUNTAGENCY Q FEDERAL-AGENCY <br /> �J ( V' f'J ❑ INOIVIMIAL Q COHNSYAGENCY <br /> CITY NAME /i �y��JSTATE CZIP CODE SITE PHONE#, AREA CODE <br /> A 6 <br /> TYPE OF BUSINESS: 0 2 DISTRIBUTOR �ESSOR ✓13ax if INDIAN EPA ID q <br /> RESERVATION N o17ANK's <br /> ❑ 1 GAS STATION ❑3 FARM TRUST LANDS ❑ ATTH1551TE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) f PHONE II WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) / PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE P WITH AREA CODE <br /> SWC« <br /> H. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 7,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Q 5 'L <br /> MAILING or STREET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Q 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 FOR BOTH LEGAL NOTIFICATION AND BILLING: I. z 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY S JURISDICTIONS AGENCY S FACILITY ID S S of TANKS at SITE <br /> [H] © e 11,9- 1o r� o <br /> CURRENT LOCAL AGENCY FA ILITY ID 8 APPROVED BY NAME PHONE N WITH AREA CODE <br /> -TT 5 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATIDN DATE <br /> LOCAT�IO'yN CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> LOCATION <br /> [ 7_. Lf W YES NO <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, <br /> �RM A(3-2-88) <br /> �--� DATA PROCESSING COPY <„� <br />