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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION _m <br /> I G' COMPLETE THIS FORM FOR EACH! ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT Er5 CHANGE OF INFORMATION ❑ 7 PERMANEj{jLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILI SITE NAME CARE OF ADDRESS INFORMATION <br /> � fS C O <br /> ADDRESS P NEAREST CROSS STREET ✓80 bY�e ❑ PARTHEPSNIP E3 STATE AGENCY <br /> O / U tiw O ❑ covoIRTN7N 13LOGL�AGENCY ClFEODW-AGENCY <br /> ❑ MINIM ❑ COUNTY AGENCY <br /> CITY NAME I STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> t(,✓l/!Y CA 5 e',3 ao 5 <br /> TYPE OF SINESS: ❑2 DISTRI R ❑4 PROCESSOR ✓Box if INDIAN EPA IDN Mol TANK'N <br /> f GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS or ❑ AT TNIB SITE <br /> SMISMof <br /> EMERGENCY CONTACT PERSON(PRIIi EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) P NEN WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS. NAME(LAST,FIRST) PHONE ITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILWG or STREET ADDRESS ✓Box lo,,,mcale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME I ZIP CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION 6 ADDRESS — (MUST BE C MPLETED) <br /> NAME CARE OF PRESS INFORMATION <br /> MAILING a STREET ADDRESS ✓ISO z la icale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPOR TION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUA ❑ COUNTY-AGENCY <br /> CITY NAME STATE IP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOYB ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATIO ND BILLING: L ❑ I. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY NOWLEDGE,/$TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED B SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION M AGENCY N FACILITY ID N N of TANKS N SITE <br /> ® 1 l 1 1 d n 00 1 <br /> CURRENT OCAL ADEN Y FA IT'Ip• APPROVED BY NAME PHONE N WRN AREA CODE <br /> PERMIT NUMBER f PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION C DE CENBU TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN SLED DATE FILED ^ <br /> t 3 _VD YES [] NO [-] r% <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <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(3-2-88) <br /> Imp J <br />