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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 5• '*. <br /> A <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE24 <br /> � FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; <br /> �l COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 1fr5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE O <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W <br /> wW <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION W <br /> M� <br /> ADDRESS NEAREST CROSS STREET ✓Bub bEiraV D PPRINERSHIP D STATE AGBICI �wV <br /> / D 001FOPAn014 D LOCAL CEO D FEBEPu AGENcr <br /> U r V OeCA D WIVIDlAL ❑ COLKIYAGB CY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> r CA `!53&(o <br /> TYPE OF BUSINESS: ❑p IBUEOR ❑4 PROCESSOR ✓Box B INDIAN EPA ID a F of TANIh <br /> E GAS STATION -3 FARM ❑SOTHER TRUSTYATION LANDSm ❑ AT THIS SITE J <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(UST,FIRST) PHO14E N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> c% e 2[79- 9 Y� _`.iv one <br /> NIGHTS: NAME(LAST, ST) J PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE M WITH AREA CODE <br /> A.T/TA.G <br /> II. PROPERTY OWNER INFORMATION&ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 177rGLiae913e,7'.14 <br /> MAILING or STREET ADDRESS IF ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME a STATE <br /> ZIP CODE PHONE#,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I/Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY 13FEDERAL-AGENCY <br /> ❑ INDIVIDUAL DCOUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WION ABOVE ADBRBBB SHOULD BE USED FOR IOTA LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 111. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION k AGENCY» ILITYID*' x of TANKS at SITE <br /> 3 c D O o <br /> CURRE CAL AGENCY FACILITY ID N APPROVED BY NAME PHONE k WITH AREA CODE <br /> PERMIT N MIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> E <br /> DE CENSU7STRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> a3 ao� a-(O YES NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY: <br /> a�qo <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 ONL . <br /> FORM A(3-2-138) <br /> 3/ �Q DATA PROCESSING COPY <br />