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STATE OF CALIFORNIK' WATER RESOURCES CONTROLBOARD o ' <br /> �)FORM 'A'- UNDERGROUND STORAGE TANK PROGRAM � n <br /> SITE 1� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION (o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <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 TEMPORARYSITE CLOSURE00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> llezki-1 / alt— <br /> ADDRESS / / NEAREST CROSS STREET ✓Ambi ENCY <br /> PAINEREW ❑ STATE AG <br /> SIO 3/ .f 7�7/en Lst G��' ° INDIYIWAL� °❑ COUNTY AGENCY <br /> BX,Y 1:1RiE0.ALAGDKY <br /> CITY NAME / STATE ZIP CODE SITE PHONE M,WITH AREA CODE <br /> � :poelr CA 9502 ( ) 1 u lc_ <br /> TYPE OF BUSINESS: ❑2 BUTOR ❑ 4 PROCESSOR I ✓Box 4 INDIAN EPA ID p _ ♦of TANI <br /> RESERVATION or /// AT THIS SITE D <br /> ❑ 1 GAS STATION 3 FARM ❑5 OTHER TRUST LANDS ❑ L� <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> r <br /> NIGHTS: NAME(LAST.FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME Q CARE OF ADDRESS INFORMATION <br /> �1/ i <br /> MAILING or STREET ADDRESS ✓Bo moimo ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ RPORATION ❑ LOCAL-AGENCY ❑ FEDERA4AGENGY <br /> INDIVIDUAL El COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS I RMATION <br /> 5l z' <br /> MAILING or STREET ADDRESS ✓B 0inoiwle ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 441�11. ❑ uL❑ <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 p JURISDICTION If AGENCY# FACILITY ID R 8 of TANKS P7 SITE <br /> CURRENT LOCAL AGENCY FAG TY ID.N� APPROVED By M PHONEp WITH AREA CODE <br /> KE <br /> PERMIT NUMBER PERMIT APPROVAL DATE P RMITE (RATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT.3 CODE BUSINESS ES[:]D NO j OA E FILED <br /> CNECKp PERMIT AMOUNT SURCHARGE AMOUONT^C FEE CODE RECEIPTp LTJ( BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST_(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-5&) <br /> DATA PROCESSING COPY <br />