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STATE OF CALIFORNM WATER RESOURCES CONTRZfL BOARD <br /> etf 'Af <br /> v_ A <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM A" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> 2 COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMAN Y CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 16,11 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILI SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS m/ NEAREST CROSS STREET ✓Bmbn&sle ❑ PAMNEFISIIP ❑ STATE AGEKC <br /> UC \ TUY� <br /> 13 INDIVIDUAL Elowm AGENCY <br /> CITU NAME , ` 7 q ' STATE ZIP CSE SITE PHONE p, AREA <br /> 01) <br /> TYPE OF BUSINESS F-1 2 DISTRIBUTOR/❑✓4 PROCESSOR ✓Box if INDIAN EPA ID N , C vt <br /> RESERVATION or ❑ �j „� AT THIS SITE <br /> ❑ I GASSTATION FARM ❑ 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAM (LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(IAST,FIRST) PHONE N WITH AREA CODE <br /> Cao 31- 7 " <br /> NIGHTS. NAME(I-AST.FIRST) �, p P ONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE B WITH AREA CODE <br /> <S moi'J�✓��' <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME S CARE OF ADDRESS INFORMATION <br /> J t� <br /> MAILING or STR ADDRESS ✓Box to,odioete ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME • � E% / CARE OF ADDRESS INFORMATION <br /> MAILING or STRE ADDRESS c/,[`tea ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> -71 CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 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 R JURISDICTION E AGENCY R FACILITY ID N R of TANKS of SITE " <br /> CURRENTLOCAGEN <br /> AL CY FACILITY 1%N APPROVED BY NAME PHONE N WITH AREA CODE <br /> f <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIO CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> •) �,7L­ YES NO El <br /> CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <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 INFORMATION ONLY. <br /> FORMA(3-2-83) <br /> ^ .()v <br />