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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 6. <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMAXt CLOSED SITE N <br /> Q. <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Qy <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETE &'r"/ - 070-2Z- Z N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> G;N� fo e <br /> ADDRg NEAREST CROSS STREET ✓Box to inera@ ❑ PARTNERSHIP ❑ STATE AGEND <br /> Q�I <br /> II <br /> �1 El INDIVIDUALCORVItON LOCAL AGENCY❑ COUNTY AGENCY [I FEDERAL <br /> CITY NAME AC / STATE ZIP CODE SITE PHONE It,WITH AREADE <br /> O K CA s�ZOS— - (7 , -3 <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I/Box if INDIAN EPA ID aESEof TANK's <br /> 1 GASSTATION [:] 3 FARM ❑ 5 OTHER TRUSTY <br /> LANDS ATION Or ❑ <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 4 WITH AREA CODE <br /> M6 E'NO '$53 <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 OFADDRESSINFORMATION <br /> AS� `TeNe D 1 <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 6 G ❑ CORPORATION. ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> J ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME ST ZIP CODE PHONE k,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE 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. ❑ I. ❑ 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 N JURISDICTION N AGENCY N IDN F of TANKS at SITE <br /> u <br /> jo <br /> CURRE 0CAL AGENCY FACILITY ID N APPROVED BY NAME / / PHONE M WITH AICEA CODE <br /> PE BER MIT APPROVAL DATE PERMIT E%PIRATION DATE <br /> LKIN <br /> E CENSUS TRACT% SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED <br /> ZZ� 2S-� YES NO i/170 <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# B <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. . 1 <br /> FORM A(3-2-58) nC <br /> Ad `y/-G-F. 'OSIC DATA PROCESSING COPY <br />