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` <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ° <br /> :. _ <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM 7 �e <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -® : l o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 3 ° .ow„,P <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTL LOSED SITE I-+ <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1I <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) CO <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Bmw Cl PAMEMP ❑ STATE-AGENCY <br /> 10 S G Ice-- L_aL_ L[L� ❑ aN El LOcuAGOICY El FEDERAL-AGM <br /> INDMWAL ❑ CO'JNIYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> L«dP�, cA <br /> TYPE OF BUSINESS. ❑ 2 DIST OR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID p <br /> ❑ I GAS STATION FARM ❑ S OTHER TRUSTMLANDS ATION or ❑ aIE_-- AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(1-AST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Iy r <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING or STREET ADDRESS ✓Box tlicale 11 PARTNERSHIP 13STATE-AGENCY <br /> ❑ <br /> RPG <br /> RATION ❑ LOCAL-AGENCY 11FEDERAL-AGENCY <br /> )NAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 51.9 Z <br /> MAILING or STREET ADDRESS Bo. ,tate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> DIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP GOOF PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION B AGENCY P FACILITY ID# It o/TANKS H SITE <br /> 3q 0 1 L� I 1 © oma 1 / <br /> CURRENT L AL�AfjENCYFA¢ILjTjY IDZI APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER r/]1 �I/J//✓✓�'�I(p��11.- I/ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION <br /> CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> ( 3d3 3 C/ YES ❑ NO ❑ I to --13 <br /> CHECK) PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> c <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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />