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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ':' '+a <br /> FORM A : UNDERGROUND STORAGE TANK PROGRAMLm <br /> SITEifACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> (/ <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 LY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El6 TEMPORARY SITE CLOSURE �3 <br /> fJl <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 4A <br /> FACILITY/SITE NAM /1 CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Soeta indicate D PARTNERSHIP [I STATE AGENCY <br /> C ` � '• ,1 /J -� ❑ CORPORATION ❑ LOCAL AGENCY [I FEDERAL ACENcr <br /> ❑ INDIVIDUAL ❑ COUNTY <br /> NnAGEAGENa <br /> CITY NAME STATE ZIPCODE SITE PH NE p,WITH AR P CODE <br /> iftli CA ZU —I <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID x p of TANK's <br /> E] 1 GASSTATION [:] 3 FARM ❑ 5 OTHER TRUSTYLLANDS ATION or ❑ AT THIS SITE (/ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME,LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> e 20 ,83f-12� <br /> NIGHTS'. NAME(LAST,FIRSOf E#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) I <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATEAGENCYI <br /> ❑ CORPORATION D LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE ft,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. 0 II. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY p JURISDICTION R AGENCYIN FACILITY ID 8 R of TANKS at SITE J <br /> [1j] = = �46 1 161 ovv <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE K WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> _ LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> YES NO ✓] <br /> CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTk BY: <br /> (r <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAAT(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S). I INLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-288) V <br /> DATA PROCESSING COPY <br /> I <br />