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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAMf o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 1 J CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) I o <br /> FACILI /SI ENAME 5 CARE OF ADDRESS INFORMATION <br /> ADDRESS H/1^)`N / N ST CR SSTREET ON 10,,ouk ❑ wNERSHIP STATE-AGENCY N <br /> ❑ CORPOAAiION ❑ LOCAJNLL AGENCY ❑ FEDERAL <br /> ❑ INDIVIDUAL O LOCAL <br /> CITY NA STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA ixp <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑4 PROCESSOR I ✓Box,f INDIAN EPA ID N <br /> RESERVATION or Qv/ N of TANK'N <br /> ❑ I GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ / f( ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> D NAME(I ST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> fea,rsor) <br /> NIGHTS. NAME(LAEft.FIRST) PHONE N 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 /> v`S <br /> MAILING or STREET AD ESS ✓Box to intlicate ❑ PARTNERSHIP STATE-AGENCY <br /> ❑ CORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> r [IINDIVIDUAL Cl COUNTYAGENCY <br /> CITY NA STATE ZIP CODE T PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE DDRE INFORMATION <br /> MAILING rST EET DRESS ✓Box to intlicate O PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION Cl LOCALAGENCY ❑ FEDERAL-AGENCY <br /> �0 ❑ INDIVIDUAL Cl COUNTYAGENCY <br /> CITY NAM` STATE ZIP COO); L PHON p,WITH AREA CODE D <br /> G 67� I/ <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: 1. ❑ if. ❑ III.xr <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 M JURISDICTION N AGENCY R FACILITY ID N N of TANKS at SITE <br /> [�U = = 1 ,016111alZYacro <br /> CURRENT LOCAL AG CY F CILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACTMO SUPERVI� TRICT CODE BUSINESS PUNFILED <br /> NO DATE�L <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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. r <br /> FORM A(3-2-88) — <br /> \ w.� DATA PROCESSING COPY <br />