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STATE OF CALIFORND4 WATER RESOURCES CONTROL „OARD <br /> FORM 'A': <br /> SI <br /> T UNDERGROUND STORAGE TANK PROGRAM ^ <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> ITARK EM I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OFINFORMATION <br /> E0 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE PERMANENTLY ED SITE )..a. <br /> CD <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) coO <br /> FACILII SITE NAME N <br /> CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> /JCA/] NEAREST CROSS STREET ✓Bwrosdiolle ❑ PP ERSIIP 11STATE-AGENCY <br /> J ' �Vo lf/'V./-/ KC/� C�PDRATM <br /> CY ❑ AGM <br /> CITY NAME WNDALIll 00UHTAGEN <br /> STATE ZIP CODE SITE PHONE a,WoITH AREA CODE <br /> TYPE OF BUSINESS: CA � Q <br /> 2 DISTRIBUTOR 4 PROCESSOR ✓Bax it INDIAN EPA ID a <br /> 0 1 GASSTATION F-1 3 FARM 5 OTHER TRUST LANDS or ❑ - #of TANK'S <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> rC <br /> NIGHTS: NAME(LAST,FIRST) PHONE ITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S 11. PROPERTY PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CAPE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> It g , ��` / 11 CORPORATION C3LOCAL-AGENCY IDFEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODEP ONE N.WITH AREA CODE <br /> CA a Yo &ao 33`f-W7 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMES119CARE OF ADDRESS INFORMATION <br /> MAILING or STRE ADDRESS ✓Box loindicale El PARTNERSHIP 13STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE if 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. 11. 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# JURISDICTION Al AGENCY R ACILI M of TANKS at SITE <br /> 4aDo I D <br /> CURRENT LOCAL AGENCY FACILITY \to APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION DE CENSUSTR'A'TCT# SUPERVISOR-(DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> t as 3a.5 YESE] NO � a a9 e <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 /> ORM A(3-2-BB) <br /> DATA PROCESSING COPY <br />