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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> W <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM = " <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE !xo"-"�" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION EV 7 PERMANENTLY CLOSED SITE47, <br /> PV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 61 1 1. <br /> CFf <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) V <br /> FACILITY SITE NAME CARE OF ADDRESS INFORMATION <br /> p li <br /> ADDRESS G /'�v ,• 1 NEAREST CROSS STREET ✓B.1.tirale 0 PARTNERSHIP 0 E <br /> STATAGENI <br /> p b J ,341�t/' Cl 0 CORPORATION 0 LOCAL AGPaZ 0 FEDERAL-AGENcr <br /> AEV� INDN'IDUAL 0 001 AGENCY <br /> CITY NAME W NWPN STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA 2 34 <br /> TYPE OF BUSINESS. ❑;,DISTRIBUTOR 4 PROCESSOR ✓Bax if INDIAN EPA ID N <br /> RESERVATION orN of TANK's <br /> E] 1 GASSTATION 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 N WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate C PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAM Es / CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS f <br /> CNECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ 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 N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> ' I I I I / <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 23.23 J 2W4YES NO W87 <br /> CHE K N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT p Y. <br /> THIS FMUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(5), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL . <br /> FORM-A(3-2- ) <br /> `v �/ DATA PROCESSING COPY �/ <br />