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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM o <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION e <br /> to <br /> /' COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENT CLOSEDSITE <br /> ONE ITEM [:]Z INTERIM PERMIT ❑4 AMENDED PERMIT 1-16 TEMPORARY SITE CLOSURE Q} a0 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> GJ <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION W <br /> Do 's is Arco ={ <br /> ADDRESS r (� p� N RE ST CROSS STREETT ✓Bmwh*w 0 PAfBNRw 0 SrATE-ASENG' O <br /> E8, o �r 6 0 ice /-� O INDMWAL 13 LarAGDOMAINN1 rEtt+w-ACRux <br /> ❑ 0DIMWAL 0 LOINIYAGBICI SII <br /> CIN NAME Itz l STATE CO E � SITE oH0 p,WITH AREA CODE <br /> 57 <br /> TYPE OF SINESS: ❑ ISTRIBUTOR ❑4PROCESSOR ✓Box B INDIAN EPA ID N /INY`K— On` (p 7 7 <br /> RESERVATION or N M TANK'S <br /> 1 GAS STATION ❑ 3 FARM ❑50THER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> a'7- <br /> NIGHTS'. NAME(tA3 ,FIRST) PHONE WITH AREA CODE NIGHTS: NAME(AST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indioale Cl PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRE - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box toinaioste 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 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 ABOYB ABDBBSS SHOULD BE USED F BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, D TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION N AGENCY M FACILITY ID N #of TANKS at SITE <br /> CURRENT LOCAL AGENCY CI ITY ID APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMITN IA A R PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA OM ODE US JAC SUPERVIS�ISTRICT CODE BUSINES,P SNFILED NO ❑ DATE FILED ^ <br /> to <br /> CHECKN PERMIT AMOUNT SU HECEIPTN ARGE AMOUNT FEE CODE R /gLED <br /> BY: UfJ <br /> THIS FORM MUST BE ACCOMPANIED BYAT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> VJFORM A(3-2-RR) J\ <br /> DATA PROCESSING COPY -� <br />