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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 o <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE <br /> MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PER NENTLV CLOSED SITE J <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ /AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE '� f4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) r <br /> A <br /> FACILITY/SITE NAME - CARE OF ADDRESS INFORMATION <br /> r <br /> ADDRESS rr NEAREST CROSS STREET to irdirace ❑ PAAINOBNP ❑ STATE-AGEI#Y <br /> OJ Uk PJ ❑ INgYIWAI lie N ❑ COUNTY 0 LOCAL ❑ FEOEAALAUM <br /> CITY NAM f STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA Q5.2oS- — KS'-5'83 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR YROCMR ✓Box if INDIAN EPA IID` e <br /> #RESEpp K W TANK'# ' <br /> ❑ 1 GAS STATION ❑3 FARM 5 OTHER TRUST dr 1:1 No to , I AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Pr le r3 <br /> NIGHTS: NAME(LAST.FIRST) PHONE AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> i <br /> i <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFOR <br /> ' MAT <br /> MAILING or STREET ADDRESS ✓Boz toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NA / CARE OF ADDRESS INFORMATION <br /> QS <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE it.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADORES$SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ 111.❑ <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# JURISDICTION# AGENCY# FACILITY ID# If of TANKS at SITE <br /> ffal = = 10 0 / T�z= 101013 01 <br /> CURRENT LOCAL AGENCY FACILITY 10# APPROVED BY NAME PHONE#WITH AREA CODE <br /> O' � o <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR- TRICT CODE BUSINESS PLL <br /> DAT FILEVESNO3126CHECK# PERMIT AMOUNT SDRC ARGE AMOUNT FEE CODE EIPT# 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 INFORMATION ONLY <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY �, <br />