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z <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> .. <br /> „ a <br /> FORM A: <br /> !!�� UNDERGROUND STORAGE TANK PROGRAM ' �o <br /> SITE /1 I FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; <br /> ,0' COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT RTe5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE10 z <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) I <br /> F / T AME CARE OF ApFfSS INFORMATION <br /> ARES CROSSSTREET ✓3n,to olmte ❑ PMTNEPSNIP ❑ STATE-AGENCY N <br /> ADDRESS MM <br /> ❑ WRORATION Cl LOCN-AGENCYDEM ENLY <br /> ' ❑ INDIVIDUAL ❑ ODUNn AGEND 1 <br /> STATE CODE ITE PH E N WITH AREA CODE <br /> CA Ifinor 1 <br /> TYPE OF BUSwESS: ❑ 2 DISTRIBIfIOR ❑4 P LESSOR ✓Box tl INDIAN EPA ID # <br /> RESERVATION or RoI TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ ATTHIS SITE Il <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: ME(LAST.FIRST) PHONE I WITH <br /> ARRECODE DAYS,, LA (LAST,FIRST) P E#WITH AREA CODE <br /> NIGH I WE(LAST,FIRST) PHONE R WITH AREA CODE NIGHTS: E(LAST,FIRST) SJj E#WITH AREA CODE <br /> a - <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME A,� CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS 4 ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> It, W ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME H STATE ZIP CODE PHONE R,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME ` CARE OF ADDRESS INFORMATION <br /> Jl <br /> MAILLNO or STREET�'ADDRE .� �j y I/Box to indicate 13PARTNERSHIP 11STATE-AGENCY <br /> D# (J ❑ CORPORATION 11LOCAL-AGENCY 11FEDERAL-AGENCYTJ ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITU N9AIE��, /1 STATE ZIPCODE PHONE#,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. ❑ II. ❑ IIL❑ <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 R JURISDICTION R AGENCY R FACILITY IDR R o/TANKS M SITE <br /> 1610 1l Ir 1 *7 1� ao I a <br /> CURRENT LO�A094CY FACILITY ID R APP V � PHONE R WITH AREA CODE <br /> 6 LS <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> I <br /> LOCATION CODE CENSUS TRACT SUPERVISO ISTRICT CODE BUSINESS PLAN FILED - O E IL <br /> YES ❑ NO V <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# Y: <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 /> HM A(3-288) C/ <br /> ` DATA PROCESSING COPY l <br />