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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> 9Pn� ..TRF,. <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM u Z <br /> SITE /� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o 10 <br /> l/ COMPLETE THIS FORM FOR EACH CILITY/SITE ^���aa�" <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE OC;L_ <br /> 1 00 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> co <br /> FACILITY/SITE NAME '/— CARE OF ADDRESS INFORMATION <br /> ro <br /> R I'UCk - .SiJMG <br /> ADDRESS NEAREST CROSS STREET ❑ PAFTNE15HIP ❑ STATE AGENCY <br /> 4 p IB�EGAPDHATIGN O LOCAL AGENCY D FEDERAL AGDKY <br /> -5"7 <br /> m D INDMDUAL D COUNTY AGNEY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA %533 coq-33 - v� <br /> TYPE OF INESS: ❑ p DISTR18UTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID # <br /> I GAS STATION 3 FARM 5 OTHER RESERVATION or - #of TANK's <br /> ❑ ❑ TRUST LANDS ❑ NO Nie- 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 /> c k <br /> , <br /> PHONE#WITH AREA CODE a <br /> NIGHTSH A CONIGHTSNAME(LA T,FIRST) <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓ o intlicate D PARTNERSHIP D STATE-AGENCY <br /> CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Dox W intlicale D PARTNERSHIP D STATEAGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL AGENCY <br /> D INDIVIDUAL D 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. 11. ❑ Ill. ❑ 'i <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 K AGENCY R FACILITY ID M R of TANKS at SITE <br /> FIR v Y 8 <br /> CURRENT LOCAL AGENCY FACILITY ID# 7o APPROVED BY NAME PHONE X WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODECENBUS TRACT f/ d � SUPERVISOR-DISTRICT CODE BUSINESS PSN❑FILED NO ❑ DATE FI/O/ �� <br /> CHEECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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(3-2-811) <br /> ,,� DATA PROCESSING COPY J <br />