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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE L FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION B <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑7/P TLY CLOSED SITE N <br /> ONE ITEM ❑ Z INTERIM PERMIT E] 1 AMENDED PERMIT 1-16 TEMPORARY SITE CLOSURE !� / Gn <br /> I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) d <br /> FACILITY/SITE NAT T. <br /> /s `O CARE OF ADDRESS INFORMATION <br /> ADDRESS J �V/ IA.-/l�vA l� NEAREST CROSS STREET ✓Bm0 n&Ac ❑ PARTNERSHIP ❑ STATE AGENCY <br /> 0 CORMT N 0 LOCALAGDO 0 FEDERAL-AGENCY <br /> 0 NDNiDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATEZIP CODE SITE PHONE p,WITH AREA CODE <br /> rG CA � I <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box N INDIAN EPA ID n <br /> RESERVAT10N or #01TANK'# I <br /> ❑ 1 GAS STATION [:]3 FARM El OTHER TRUST LANDS ❑ AT THIS SITE <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#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#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 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> COV NAME STATE ZIP CODE PHONE At,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. ❑ II. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# If of TANKS at SITE <br /> CURRENT LOCAL AGENQMFACILITY ID# APPROVED BYNAME PHONE If WITH AREA CODE <br /> Na v <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION Cf�DE FPERIMIT <br /> 8U8 T�MCTY SUPERVISOR-DIS CODE BUSINESS PLAN❑FILED NO ❑ DATE FILED //�� <br /> CHECK N# (( AMOUNT^V SURCHARGE AMOUNT FEE CODE RECEIPT# BC <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST MI OR MORE TANK PERMIT FORM `B'APPLICATION(S), UPI ESS THIS IS A CHANGE OF SITE INFORMATIONONLY. <br /> �FORM A Is-z-eeT <br /> DATA PROCESSING COPY 4.01 <br /> — I <br />