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STATE OF CALIFORNI'r / WATER RESOURCES CONTROL ABOARD °` •� 'a <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE /�_ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> �7 COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 p N SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 3 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME I x CARE OF ADDRESS INFORMATION N <br /> Gn 8 s dG l,i t= <br /> ADDRESS <br /> NEAREST CROSS STREET ✓ A ❑ FAANE 13 STATEAGENC'S ( I El OMRTIION 11 IOG-1GENC! <br /> ❑ fEaE}V1-RGBlCY ' <br /> ❑ IMMOUAL ❑ WUNTI AGDICY <br /> CIN NAME STATE ZIP CODE SITE PHONE M, H AREA CODE <br /> A-Go�M o U <br /> TYPE OF BUSINESS: ❑ CA <br /> 2 DI IBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID N <br /> RESE❑ 1 GASSTATION [LKFARM ❑ 5 OTHER TRUSTVLANDS ATION Gr ❑ AT If ofTANKS <br /> SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME ILA$T,FIRST) PHONE N WITH AREA CODE <br /> Uk <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA C <br /> ODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME 0 CARE OF ADDRESS INFORMATION <br /> I> ' o g <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ STATE-AGENCY <br /> 0 ex g� ❑ CORPORA110 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> YYY ❑ INDIVIDU ❑ COUNTY-AGENCY <br /> CITU NAME �+ � STATE21P C^' PMO p,WITH AREA CODE <br /> (J 3�1 K <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BEC MPL TED) <br /> NAME CARE FADDRESS INFO N <br /> 5a,64 a S <br /> MAILING ar STREET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ClCORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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: 1. 11. 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 S,SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY N FACILITY ID N k of TANKS at SITE <br /> 39 = = 1010 / 13A1010101 / 1 <br /> CURRENT LOCAL ADEN Y FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE <br /> 7J)� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIO ODE CENSUS TRACT M SUPERVISOR-DISTRIC <br /> T CODE BUSINESS PLAN FILED DATE FILED <br /> -2,32- -) 3 'L(/ YES [:] NO /s(� <br /> CHECK F PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: (N <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 ON Y <br /> ORM A(3-2-08) <br /> DATA PROCESSING COPY <br />