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STATE OF CALIFORNIA WATER RESOURCES CONTROrOOARD <br /> d <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM IF <br /> SITE /c/ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P Y CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 6 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS O /f� jJ NEAREST ._O_SS_S,T,R`EET ✓COWNAe ❑ PAMLODL AGEI ❑ STATE FEDEPAGENLY <br /> IVyA /�' 12 4,7v uf' /N ❑ INDNIWAL ❑ COUNTY AMCY iFDEAM AGFNC/ <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA f � G' <br /> TYPE OF BUSINESS: ❑ 2DISTRIBUTOR ❑ 4PROCESSOR ✓Ro if INDIAN EPA ID # Mot TANK'N <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUE VIANDS ATION or ❑ 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 A WITH AREA CODE <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 /> MAILING or STREET ADDRESS ✓Box to intlicele ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE M.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box Lo md,cete ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH A NIVB AGONBSS 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION R AGENCY K FACILITY ID N Mol TANKS at SITE " <br /> [M] = = 025 <br /> CURRENT LOCAL AGENCY FACILITY ID N 2 APPROVED BY NAME PHONE N WITH AREA CODE <br /> 54s,4 f<- 7 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CQDE CENSUS TRACTN SUPERVISO"ISTRICT ODE BUSINESS P FILED DATE FILED <br /> 9 G/j 2 Z 2— ❑ E]YES NO 7_/ 4�f <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUAT FEE CODE RECEIPT N BY: /N j�C' <br /> THIS FO UST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A( <br />