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STATE OF ICALIFORNIPw WATER RESOURCES CONTROL-BOARD a `"'"' .,,, <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION l o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 1"a <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> O <br /> FACILDV/SITE NA CARE OF ADDRESS INFORMATION <br /> ADDRESS - NEAREST CROSS STREET ✓Bm bv6G@ 0 PARTNE16HIP 0 STATE AGEA'6Y <br /> Z 0 CgIPORAT10N 0 LOCAI.AGFNp 0 PEDE W AGENCY <br /> SF2 ❑ INDMDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> CA 20 0 ov <br /> TYPE OF BUSINESS: ❑ 2 STRIBUT ❑ 4 PROCESSOR I/Box it INDIAN EPA ID # <br /> RESERVATION or M 01 TANK's / <br /> ❑ 1 GAB STATION LZ3FARI ❑ 50THER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> GI ;'/ 20 - S3s-9 0o y <br /> NIGHTS: A (LAST,FIR ) PHONE a WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE*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 indicate Cl PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 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. ❑ if. ❑ 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 R JURISDICTION K AGENCY M FACILITY ID N k of TANKS at SITE <br /> &')I c2 o / <br /> CURRENT LOCAL AGENCY FACILITY ID It APPROVED BY NAME PHONE N WITH AREA CODE <br /> vile <br /> PERMIT NUMBER PERMIT ROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESSPSN FILED NO ❑ DATE FILED117- <br /> CHECK <br /> CHECK* PERMIT AMOUNT So CHARGE AMOUNT FEE CODE RECEIPT* BY: �__/ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST 0)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> '✓ DATA PROCESSING COPY <br /> \ i <br />