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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION %m 7 <br /> :o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY 0 SITE I-•y <br /> ONE ITEM E]2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / —4 <br /> ] I'" <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) CO <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION A <br /> ADDRESS NEAREST CROSS STREET I ✓W W Mtlk D PARTNERSYP D STATE AGDO <br /> D COAPCRAPON D LCCLL#GENCY D FEXW AGENLY <br /> CITY NAME <br /> ❑ YWIWAl ❑ CWNTYAGENC! <br /> STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> CA <br /> TYPE Of BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box 0INDIAN EPA 10 x <br /> ❑ 1 GAS STATION E] 3 FARM ❑ S OTHER TRUSTYLANDS or 1:1A of TANK'S <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE R WITH AREA CODE DAYS: NAME)LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING m STREET ADDRESS ✓Boz tom"""" El D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> D INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING m STREET ADDRESS ✓Box to mcIcate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERALAGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 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: L ❑ 11. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL TY 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 /> COUNTY11 JURISDICTION R AGENCY 3 FACILITY ID B Al of TANKS 31 SITE <br /> Cl�l = = I I I 1A tl I& - <br /> CURRENT LOCAL AGENCY FACILITY ID 0 APPROVED BY NAME PHONE Y WITH AREA CODE <br /> i <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT Y SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DApTE�FILED <br /> YES NO O �� <br /> CHECK F PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Y B <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 L . <br /> �FOnR�-2-BB) <br /> /.i V" DATA PROCESSING COPY <br />