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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 21 CHANGE OF INFORMATION ❑7—PEEMAUEWILYCLOSEDSITE fV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE IJ <br /> r <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) p <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> 4 NEARM CROSS STREET ✓S.HHdral, El PARINB�HIP 11STATE-AGENCY <br /> (J'j�/� ❑ GG MMTHM' 0 LOCALAGENCY CIFEDBVL-AGED <br /> ❑ INDIVIDUAL ❑ 00111tt-AGEND <br /> CITY NAME STATE ZIP QODE SITE PHO E p,WITH AREA CODE <br /> r. CAy 37 <br /> TYPE OF BUSINESS: F-12 DISTRIBUTOR F-14 PROCESSOR ✓Box it INDIAN EPA ID# <br /> RESERVATION or 7101 TANICR <br /> 1 GASSTATION [:] 3 FARM ❑50THFA TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. A�T,FIRST) PHONE R WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE R WITH AREA CODE <br /> / III, R6 <br /> NIGHTS: NAME(LAST,FIfiBT{ PHON R WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE R WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE R,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRES — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE AGENCY <br /> O CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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: I. ❑ H. ❑ Ill.❑ <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# JURISDICTION R AGENCY# FACILITY ID# #of TANKS at SITE <br /> 001U06, 6 <br /> CURRENT LOCALAOENCY FACILITY ID R APPROVED BY NAME PHONE R WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION C DE CENSUS TRACTIP SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ❑ DALTEFILED ,YES NOCNECKR P RMIT AMOUNT SURCHARGE AMOUNT FEE CODE <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(3-2-881 <br /> DATA PROCESSING COPY <br />