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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD "" ` <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE G FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> IP <br /> COMPLETE THIS FORM FOR EACH FAC TY/SITE c"A,lON"�' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �a <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Bwbnf o, ❑ PAAINBISHIF ❑ FATEEAGENLY <br /> ❑ WIPO - ❑ LOCAL AGDO ❑ FEDEMLAGENC! <br /> 6 VC . o /4 6 uN ❑ COUNTYAMC( <br /> CITY NAME STATE ZIP CODE SITE PHONE k WITH AREA CODE <br /> <F-5CA 9,S3P20 ,�U9 3 -SIS?Y <br /> TYPE OF BUSINESS: 02 IBUTOR ❑4PROCESSOR -/Box if INDIAN EPA ID % %of TANK'% <br /> RESERVATION or ❑ <br /> ❑ 1 GAS STATION TRUST(LANDS FARM ❑S OTHER AT THIS SITE 1 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> m 4" vrA i" -d 50."p <br /> NIGHTS: <br /> NIGHTS: NAME(L <br /> NIGHTS: NAME(LAST,FIRST) PHONE%WITH AREA CODE AST.FIRST) PHONE%WITH AREA CODE <br /> I <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> // <br /> v / <br /> MAILING or STREET ADDRESS ox ointlicate ❑ PARTNERSHIP 11STATE-AGENCY <br /> RPORATION 11LOCAL-AGENCY 11FEDERAL-AGENCY <br /> 4;INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boxt naicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ PORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> DIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0,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. if. ❑ 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 It AGENCY% — FACILITY ID% It of TANKS at SITE <br /> U O a I <br /> CI�R OCALAGENCY FACILITY ID% APPROVED BY NAME PHONE%WITH AREA CODE <br /> MIT NUMBER PERMI PROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATTIONN CODE CENSUS TRAACTT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> N/ a3� ao2 3xsZ YES ❑ NO ❑ <br /> CHECK% PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT% BY: <br /> Cv� �l`to <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 /> �!-1�( DATA PROCESSING COPY <br />