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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> / J- UNDERGROUND STORAGE TANK PROGRAM <br /> SITE � FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FA LITY/SITE ""-°- <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑l 7 PERMANENTLY CLOSED SITE t\ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 6 <br /> v <br /> A <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME . CARE OF ADDRESS INFORMATION <br /> ( ) LL 1 L .4 <br /> ADDRESS NEAREST CRfSTREET ✓ftwIwale ❑ PwwRw ❑ STATEAGDO <br /> ❑ AraCl LOC& CE13 RGOWAEN—/ /a XkNC P DNOMDWL D ODUNT1 CENGY <br /> CORK <br /> CITY NAME —7 _ ,I STATE ZIP COQE ^ / �J F,W'E N,WITH Af jCODE <br /> l FQ^/JJ� CA 6 �p <br /> TYPE OF BUSINESS: ❑2 a BUTOR ❑ SSOR E ✓BOxESER II INDIAN EPA IO N S at TANK'L / 1 <br /> ❑ TION <br /> 1 GAS STATION [-] 3 FARM 5 OTHER TRUSTYL INDS or <br /> ❑ AT THIS SITE /0 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) � S PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING Or STREET ADDRESS ✓Go.to iMicale D PARTNERSHIP D STATE-AGENCY <br /> Cl CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE PHONEN,WITHAREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL UCOUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA WOE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION X AGENCY11 FACILITY ID R Y of TANKS at SITE <br /> ff�lCil a z% <br /> CURRENT LOCAL AGENCY FACILITY ID 4 VED BY NAME PHONE N WITH AREA CODE <br /> LPERMITNUMBER ?ERMIT tPROVALDATiEE]PERMIT EXPIRATION DATE <br /> CENSUSTRACTTaBUSINESS PUN FILED DATE FILED <br /> YES NOFPERMIT AMOUNT FEE CODE RECEIPT I BY. /J <br /> ' <br /> DJ THIS FORM MUST BE ACCOMPANIED BY ATI '"T(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONT' 'INLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> J FORM A(3-2-88) <br /> v DATA PROCESSING COPY � <br />