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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION } ' <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANE E ITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> S A e2I R-lb <br /> ADDRESS11 ,, \\ NEAREST CROSS STREET ✓BPbItlUA D PIATNOGV D SrArE 4mI O C l . - — _ O CGPONTNIN O LW rry Au IC/AGDO ❑ FEOF/UL AGENLY <br /> MwYxA <br /> CITY NAME _ STATE ZIP CODE SITE PHONE M,WITH AREA CODE <br /> I L CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR /PROCESSOR ✓Box if INDIAN EPA ID N ' <br /> RESERVATION or B of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(UST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to im.cate D PARTNERSHIP ❑ STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE 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 ✓Box to inalr to D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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: 1. ❑ II. ❑ Ill.❑ <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY F JURISDICTION N AGENCY B FACILITY ID R Y o/TANKS el SITE <br /> 2 v 1 <br /> CURRENT LOCAL AGENCY FACILITY10N--1— APPROVED BY NAME PHONE N WITH AREA CODE <br /> K I 10 1 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISORDISTRICT CODE BUSINESS PLAN FILED DATE FI <br /> YES [] NO 1Q <br /> CHECK N PERMIT AMOUNT BURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> 77T <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 /> / FORM A(3-2-BS) <br /> C� <br />