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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': ' ' <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SETTFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> / COMPLETE THIS FORM FOR EACH!F ILITY/SITE <br /> MARK ONLY ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENT Y C OSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Z <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 30 <br /> F ILITY/SITE NA IRE OF ADDRESS INFORMATION <br /> It <br /> ri <br /> A RESS NEAREST CROSS STREET Bw 10 NUN C PARTNERSHIP ❑ STATE AGENCY a <br /> �O C_a // , ❑ C09PyV,TION ❑ LOCAL AGENCY ❑ FEOERA4AGENCY �w <br /> C3'IA6-VIOIIAL ❑ COUNIY AGENCY <br /> TY NAME STATE AW CODEPH NE a,WITH AREA CODE ~ <br /> cA / —Ay/0 <br /> Y E OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 P SSOR I/Box if INDIAN EPA ID a or ❑ #of TANK'a <br /> RESERVATION11 <br /> 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS �/ AT THIS SITE / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> D - NAME(LAST,FIRST) PHONE a WITH AREA CODE Z NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> E ✓dhti o <br /> HTS. NAME(LAST.FIRST) PHONE IFIVITH AREA CODE IGHTS: NAME(LAST,FIR ) ONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> E ('� RE OF ADDRESS INFORMATION <br /> J�I� <br /> (LING or STREET ADDRESS ✓Bax to intlicate C PARTNERSHIP Cl STATE-AGENCY <br /> lb"A ❑ CORPORATION C LOCALAGENCYC FEDER L-AGENCY <br /> ❑ INDIVIDUAL C COUNTYAGENCY <br /> NAME STATE CODE NE A.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> INAME <br /> E OF ADDRESS INFORMATION <br /> 3/G or STREET ADDRESS ✓Box to intlicate C PARTNERSHIP C STATE-AGENCY <br /> C CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> C INDIVIDUAL 1:1COUNTY-AGENCY <br /> TE ZeCGDE P E A.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. if. ❑ 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 /> M37L COUNTY R JURISDICTION It AGENCY# FACILITY ID R #of TANKS at SITE <br /> 39 = a 010 10 / <br /> C NT LOCAL AGENCY FACILITY ID k C ///''''l/ VED BY NAME PHONE#WITH AREA CODE <br /> / J Sd <br /> MIT NUMBERP APPROVAL-DA/TE PERMIT EXPIRATION DATE <br /> m N <br /> TION CODE �� US TRACT N' SUPERVISOR-131 T�CO BUSINES,P5NFILED NG ❑ ILE� L �� <br /> ECK# I_EOMIT AMOUNT CHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(7)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> �. DATA PROCESSING COPY <br />