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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 4A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> cl COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 FERMANE ITE h+ <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5Z <br /> I..A, <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME �. CARE OF ADDRESS INFORMATION w <br /> ADDRESS NEAREST CROSS STREET ��✓�Hq i�9K ❑ PARTNERSHIP ❑ STATE.AGEWN <br /> 6700 zeaddetd� <br /> LA4'CRPOMTION ❑ LOCM AGENCY ❑ FEDERAL AGENCY <br /> ❑ INDMOUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 Pfl R ✓BOx if INDIAN EPA ID # <br /> LSEof TANK's <br /> ❑ I GAS STATION ❑ 3 FARM OTHER TRUSRYANDS TION Dr ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> yis 63 - 'r 24Yy / <br /> NI MTS: NAME(LAST,FAST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAtT.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 ✓8 ndicate 13 PARTNERSHIP ❑ STATE-AGENCY <br /> . O ?7 C7 ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> SII .7 J ❑ INDIVIDUAL 11COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INF MATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME `- CARE OF ADDRESS INFORMATION <br /> MAILING or STREET A�ESS ✓Box to ir,tlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> (i/1 O Cl CORPORATION IDLOCAL-AGENCY 11FEDERAL-AGENCY <br /> C/ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME - STATE ZIP CODE PHONE If WITH AREA CODE <br /> SS t <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. I. ❑ III. <br /> fj <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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> mI I I , <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EKPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 9 /7[ YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 /> DATA PROCESSING COPY *-If <br /> %/ <br />