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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE '10 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION , PERMANENT Y CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE y <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 1®y <br /> FACILITY/SITE NAME CARE OFA RESS INFORMATION <br /> "tAN <br /> ADDRESS NEAREST CROSS STR ✓Nast irI El PARTNERSHIP ❑ STATE-AGDO <br /> nn� PPOIMnON ❑ LUX-AGENCY ❑ FEDRVL-AGRXY 00 <br /> S' D (,(,{/-46 F'�-Acl INDIVmLAL ❑ C01KRAGENCY <br /> CITY N"t:E( STATE ZI SITE P ONE#,WITH AREA CODE _ <br /> TYPE OF BUSIN�• EPA DNA ����D <br /> ❑2 OISfNIBUTOR ❑ 4 PROCESSOR RESERVATION or ❑ A / _16() <br /> Mo17ANK's <br /> ❑ I GAS STATION ❑3FARM OTHER TRUSTLANDS /`� ATTHIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: ME(LAST,FIRST) PgN N WITH AREA CODE <br /> 'A 51A <br /> NIGHTS: NA LAST.FIRS11 PHONE# ITHAREACODE NIGHTS NAME(LAST,FIRST) PeNWITH AREA CODE <br /> S A JQ <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> )i, ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME M STATE ZIP CODE PHONE#,WITH AREA CODE <br /> v <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME WV � � CARE OF ADDRESS INFORMATION <br /> MIMAILING rSTREET ADDRESS ✓Box to indicate 11 PARTNERSHIP El STATE-AGENCY <br /> v" ❑ ORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> _ O INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY VME M 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. ❑ 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&SIGNATUREI DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID Y APPROVED BY NAME PHONE#WITH AREA CODE <br /> Iui}A)-LAzO <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT#� SUPERVIS R-DISTRICT CODE BUSINESS PLANFILED OAT FIL D <br /> 33 ((ffpp YES <br /> ❑ NO <br /> CNEC PERMIT AMOUNT SURCH RGE AMOUNT FEE CODE RECEIPT If BY: <br /> IS 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 /> \ FO M A13-2-&GI <br /> �r DATA PROCESSING COPY -� <br />