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STATE OF CALIFORNOr WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ T NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO D SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 3 —I <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) ul <br /> FACILITY SITE CARE OF ADDRESS INFORMATION A <br /> N <br /> ADDRESS NEAREST CROSSSTREET ✓lINIP dam, 0 PARTNERSHIP Cl STATE <br /> 76977 r v 0 CORPORATION 0 LOGILAG80 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNIYAGENCI <br /> CIN NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> sl PC CA <br /> CA s�c� <br /> TYPE OF BUSINESS. ❑ ISTRIBUIOR ❑ 4 PROCESSOR I/Box 0INDIAN EPA ID If <br /> ❑ 1 GAS STATION 3 FARM 5 OTHER TRUST LANDS SEVATION of ❑ •of TANK't <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAHE1 CARE OF ADDRESS INFORMATION <br /> ✓` I <br /> MAILING or STREET ADDRESS ✓Box to Indx,.te 0 PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP COCE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME p /y CARE OF ADDRESS INFORMATION <br /> of <br /> MAILING or STREET ADDRESS I/Box tolnEicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE R,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. El I. ❑ If. ❑ <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 M FACILITY ID R M of TANKS at SITE <br /> 3� -,-141(�7 1 10 10 16 <br /> CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE#WITH AREA CODE <br /> GI,L '�la <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> [LOCATION CODE CENSUSTRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILEDqcl23z "L5- YES ❑ NO <br /> HECK# 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. I� <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />