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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD �• ." <br /> FORM `A'• <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE ( / ' 1 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �'6�•_�`' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 CLOSED SITE N <br /> ONE ITEMQS <br /> ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE cr <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) d <br /> FACILI TE NAME CARE OF ADDRE S INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓B.e miifia 0 PARTNERSHIP 0 STATE AGENCY <br /> d SSG1n� ❑ cORPormnax 0 COUNTY AGENCY <br /> �EEOBIUL BNcr <br /> ❑ CORPINDIVIORAL 0 LOCAL AGENCY <br /> CITY NA _ STATE ZIP p SITE PHONE#,WITH AREA CODE <br /> CA <br /> Za� <br /> TYPE OF BUSINESS ❑p TRIBUTOR ❑ 4 PROCESSOR I I/Emit INDIAN EPA 10 # <br /> ❑ I GASSTATION 3 FARM 5 OTHER RESERVATION or n AT TOf of TANK's RIS SITE <br /> ❑ TRUST LANDS ❑ r-6 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE it WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> /j/ CARE OF AQDRESS INFORMATION <br /> MAILIN or STRE j,p.DBRE$S 7✓`�•I'�"' ` I//✓•,-AB/ox�lPORAATIO ❑ PARTNERSHIP ❑ STATEAGENCY3TRE (//dam/J ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDE L- ENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY ./ <br /> CITY NIWE '— - STATE ZIP CODE�� PHONE p.WITH AREA CODE <br /> lFC7 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BECOMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS -/Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDVIOUAL 0 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. ❑ If. 111.❑ <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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> O d 1 </I / 1.1--161 10 16 1 o / <br /> CURRENT LOCAL AGENJYI L7Cs4D# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PER IT NUMBER NI (J� PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIgKCODE TR T# 7 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED GATE FILED <br /> YES NO� <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> ` I 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 /> FORM A(3-2-BB) <br /> DATA PROCESSING COPY <br />