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STATE OF CALIFORNIA WATER RESOURCES CONTROLV6ARD <br /> zEf�Yas fti\ <br /> f <br /> FORM 'A': ' <br /> SITE' UNDERGROUND STORAGE TANK PROGRAM " <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m r Z <br /> ' to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE .a�,. <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION <br /> ONE ITEM ❑ 7 PERMANE )..i <br /> ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 4 <br /> I. FACILITY/SITE INFORMATION &ADD RESS - (MUST BE COMPLETED) cm <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> / S _ G <br /> ADDRESS <br /> NEAREST CROSSSTREET ✓ WWA ❑ PARTNERSHIP ❑ STAtEAGENCY <br /> CRIT <br /> CORPORATOR ❑ LWA.AGDO ❑ FEDERAL <br /> CITY NAME <br /> ❑ INOIVIWAL ❑ GWNTKAGENCY <br /> STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA �s�0 <br /> TYPE OF BUSINESS' Erlq p BUTOR 4 PROCESSOR ✓ /� <br /> ❑ Box it IN EPA ID N <br /> ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS VATION or ❑ ATTHIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) w(-fes.— PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST)N PHONE N WITH AREA CODE <br /> eic <br /> NIGHTS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE NIGHTS' NAME(LAST FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CAREOF ADDHE�IRMATION <br /> MAILING or STREET ADDRESS intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> El <br /> 11 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> /C____- <br /> 111. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFOR ATION <br /> qla- <br /> MAILING or STREET ADDRESS ointlicale 1-1PARTNERSHIP 13 STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> Cl INDIVIDUAL Cl COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> s <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. It❑ Ill. ❑ <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 M JURISDICTION K AGENCY R FACILITY ID R R o/TANKS M SITE <br /> s � C3 10vv � <br /> CURRENT LOCA AGENCY FACILITY ID Al APPROVED BY NAME PHONE N WITH AREA CODE <br /> 00NzLL / 5 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> / LOCATION CO DE CEN`888UU6TRACTM* SUPERV <br /> ISOR-DISTRICT CODE BUSINESS PLAN FI LED DATE FILED <br /> CHECK PERMIT AMOUNT SURC ARG>�UNT FEE CODE YES ❑RECEIPTING ❑ BY: <br /> 'IVI <br /> 1 <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(3-2-08) <br /> 1 <br /> DATA PROCESSING COPY <br />