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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -o l to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE o <br /> 1. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> FACILITY/SRE NAME CARE OF ADDRESS INFORMATION <br /> w at <br /> a►� ess <br /> ADDRESS NEARESVICROSS STREETb"'a" D PAMM�W 0 STATE,1GBWY <br /> WNPOMiION 0 LOCk-AG Y 0 FEO KAGENCY <br /> 3o UC N O INOIVIOUAL 0 WUN Aamg <br /> CITYNAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA pyo-55 2a - 3 —zoal <br /> TYPE OF BUSINESS: ❑2 gS7RIBUTOR ❑N PROCESSOR ✓Box'*INDIAN EPA ID a <br /> RESERVATION or k of TANK'# <br /> ❑ I GAS STATION ❑ 3 FARM 5 OTHER 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#WITH AREA CODE <br /> j <br /> ;?07-3511-20V U04 <br /> NI HTS: NAME(UST,F!RSW PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Age, 05 � <br /> MAILING or STREET ADDRESS ✓Boz to indicate D PARTNERSHIP ❑ STATE-AGENCY <br /> D CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME / CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADD ESS ✓Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> D INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <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: 1jz 11. ❑ IN.❑ <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(PRIMED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION k AGENCY N FACILITY ID# It of TANKS at SITE <br /> Kil = = 100207 / 101010b <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> NI <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> 23, YES ❑ NO ❑ C I <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-SR) S <br /> — DATA PROCESSING COPY j <br />