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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAMe <br /> SITE. FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C COMPLETE THIS FORM FOR EACH F ILITY/SITE y <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY C SITE 7j <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �Q <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME f CARE OF ADDRESS INFORMATION <br /> :TYa kvvi., yo - Lpuz-, <br /> ADDRESS NEAREST CROSS STREET ✓Bwbnddit, ❑ PABTMIGNI? 11STATE AGENCY <br /> ' / ❑ PATOY ❑ LOCAL AGENCY ❑ PEOERAL-AGENLY <br /> [ , INDNIDUAL ❑ COUNTYAGENCY <br /> CITY NAME fes, STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> 1 o C �U✓L� CA a 5 <br /> TYPE OF BUSINESS'. ❑ 2 DI RIBUTOR F-] 4 PROCESSOR ✓Box if INDIAN EPA ID N Not TAMPS <br /> RESEATION <br /> ❑ I GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS Gr ❑ 1 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 /> cc, a o q q,31-d5 <br /> NIGHTS: AME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> sa-"� <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME 51�` CARE OF ADDRESS INFORMATION <br /> MAILING or STRADDRESS -/Box to intlicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME S CARE OF ADDRESS INFORMATION <br /> MAILING or STRE 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.V, 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 B SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION# AGENCY# FACILITY ID R #of TANKS at SITE <br /> DE = = aDlole)' <br /> CURRENT LOCAL AGENCY FACILITY ION APPROVED BY NAME PHONE M WITH AREA CODE <br /> D <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> DE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESyPLAN❑FILED NO <br /> ❑ DATE ILED <br /> a i� 3 <br /> PERM 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 INFORMATIO4ONL <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY' '� ,y 1 `s <br />