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L 0 <br /> `STATE OF CA ORNIA WATER RESOURCES CONTROL BOARD ' <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT EE[15 CHANGE OF INFORMATION 7 PERMANENTLY D SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑<AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> FACILITY/ NAME CARE OF ADDRESS INFORMATION <br /> Ind7n RocoLij Co . <br /> ADDRESS �L�/ AlNEAREST CROSS STREET ✓B®bili ❑ P ❑ SIATE-AGEIv <br /> I '1 / ✓ S 1 1 �E' ❑ wlPMTON ❑ xasr ❑ FEEk GM <br /> ❑ NMK ❑ AGBILT <br /> CITY NAME ^ STATE 21P COQE SITE P NE p,WITH AREA CODE <br /> J CA G/J`✓ <br /> TYPE OF BUSINESS: ❑2 DISTRBUTOR ❑ /pROCESSOR ✓BOX E INDIAN EPA 10 M <br /> ❑ ❑ ❑ TRUSTT LANDS or ❑ AT THIS SITE 1 GASSIATION 3 FARM 5 OTHER AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT P SON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FI T) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BEC PLETED) <br /> NAME CARE OF AD ESS INFORMATION <br /> MAILING w STREET ADDRESSBox io indicale 11 PARTNERSHIP 11 STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> _ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CRY NAME TATE ZIP CODE PHONE N.WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS 4V 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 BILLIN ADDRESS <br /> CHECK ORAE(1)BOX INDICATING WHICH ADM Ap6MU SHOULD Mi USED FOR WTN LEGAL NOTIFICATION AND IIWNG: I. ❑ it. ❑ Ill. ❑ <br /> THIS FORM HAS BEEN COMPLETED U DER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SI ATURE) DATE <br /> LOCAL AGENCY USE ONLJ <br /> COUNTY R JURISDI ON R AGENCY R FACILITY ID R N of TANKS SL SITE <br /> 1010 D 17 3 D <br /> CURRENT LOCAL AGENCY F ILITV ID II APPROVED BY NAM[ PHONE F WTTN AREA CODE <br /> m L9 <br /> PERMIT NUMBER //'�/PERMIT APPROVAL DATE PEIAMR EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT $UPERVISON-0MTRICT CODE BUSINESS PLAN FILED DATE FILED [TAY <br /> YES [:] NO 3_9-id <br /> CHECK Y PERMIT AMOUNT SURCNARGE AMOUNT FEE CODE RECEIPT a BY: <br /> TINSORM 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 /> FORM A(3-2-R I <br />