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STATE OF CALIFORNIA' WATER RESOURCES CONTROL BOARD <br /> ZB. T4a <br /> y aua , <br /> { 1 <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE �f FACILITY/SITE, INFORMATION and/or P RMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER ENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION W <br /> AL_$F.(LT Xo�•• <br /> ADDRESS NEAREST CROSS STREET ✓Bmmirdide ❑ PAIifNENB1IP ❑ STATEAGENCYlV <br /> SEl 00100114110h ❑ LOCALAGDICY 13 FEDERAL AGENCY <br /> 1:1INP'M ❑ COUNTY AGENCY <br /> CITY NAME �� STATE ZIP CODE SITE PHONE# WITH AREA COD <br /> / L CA <br /> TYPE OF BUSINESS'. 2 RIBUTOR ❑ 4 PROCESSOR I ✓SIX it INDIAN EPA ID 0RESERVATION of TANK's J`� <br /> ❑ t GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS dl ❑ AT THIS SITE (� <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: N ME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 0_fEST -201-85L-V( 2 o �$?, _ <br /> NIGHTS: NA E(LAST,FI ) PHONE#WITH AREA CODE NIGHTS'. NAM (LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING o,STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE if,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME s CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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: 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FA ITY ID k #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FA # APPROVED BY NAME PHONE#WITH AREA CODE <br /> Z NmF 35 <br /> PERMIT NUMBER TE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRI CODE BUSINESS PLAN FILED DATE FILED <br /> 2(/ YES NO <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY,,.--// <br /> /N <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UPSESS THIS IS A CHANGE OF SITE INFORMATION ON <br /> FORM A(3-2-88) <br /> �" DATA PROCESSING COPY `'^'� <br />