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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT zr 5 CHANGE OF INFORMATION ❑7 PERMANENTLY C SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 t� <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAR ST CROSS TREET ✓ rd'cek ❑ PMTNERSHIP ❑ SLATE-AGBN.Y <br /> O(/ 00WORATIN ❑ LDCJL#GENLY ❑ FEDERAL-AGBILY <br /> ❑ INDIVIDUAL ❑ COUMAGEMN <br /> CITY NAME I.a! STATE ZIP CODE ITE PHONE p,WITH AREA CODE <br /> CA sa a 3� -Asa <br /> TYPEOFBUSINESS: ❑2 DISTRIBUTOR ❑4 P ✓Box R INDIAN EPA ID # <br /> RESERVATION or Rol TAN SI <br /> ❑ 7 GAS STATION ❑3FARMKll <br /> THER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Caoq <br /> NIGHTS: NAME(LAST,FIRST)�p ��� p PHONE p LTH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> K// I �� <br /> Il. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS Bdfto indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & DDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING AD RESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHO D BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY O 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 R JURISDICTION R AGENCY R FACILITY ID R a of TANKS at S1TE <br /> 1pi 4 111 <br /> CURRENT LOCAL AGENCY FACT ID* APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATIONDATE <br /> LOCATION CODE CENSUST CT# SUPERVISOR-DISTRICT CODE BUSINESS FILED NO ❑ DATE FILED <br /> `VrQ <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT R 1 BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(U 113'nR MORE TANK PERMIT FORM ' �APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> \ FORM A(3-2-88) Vase &� <br /> \ DATA PROCESSING COPY "� N, <br />