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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE .4 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1d <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT Z161CHANGE OF MFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADD`RRE/S1JS/— (MUST BE COMPLETED) 1w�, <br /> FACILITY/SITE NAME _ `l v•"=.-. CARE OF ADDRESS INFORMATION ,v <br /> ADDRESS NEAREST CROSS STREET ✓AmmivicKe ❑ PARTNEFSgIP ❑ STAITAGFNCY <br /> 7O — ❑ CONPO TIDN ❑ U)CMAGENCY ❑ FEDEMLAGOO <br /> ❑ INDIVIDUAL Cl COUNW AGENCY <br /> CITY NAME STATE ZIP CODE PHON #.WITH AREA CODE <br /> CA c20 <br /> TYPE OF BUSINESS: ❑ 2 DISTRI6UTDR ❑d P R ✓Box if INDIAN EPA ID a <br /> ❑ GAS STATION 3 FARM OTHER RESERVATION orF-1 - X of TANK <br /> ❑ TRUST LANDS <br /> 1 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 N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADD ESS ✓Box 4ioate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ PORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> NDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 3 <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 /> CITY NAME STATE ZIP CODE f PHWTH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> 'CHECK (1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ H. 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 M AGENCY k FACILITY ID R R of TANKS BI SITE <br /> av] = = 0 -3v 100101 <br /> CURRENT LOCAL AGENCY FACILITY ID NAPPR PHONE It WITH AREA CODE <br /> IR.-S <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EKPIRATION DATE <br /> LOCATION CO E CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL <br /> YES No <br /> CHECK# 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 /> FORM A(3-2-88) <br /> \ i DATA PROCESSING COPY K( <br />