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STATE OF CALIFORNP WATER RESOURCES CONTROCBOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM VoZ <br /> SITE 7� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION l o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EV CHANGE OF INFORMATION ❑ 7 PE NTLY CLOSED SITE 10" <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 'J <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) CTI <br /> FACILITY/SITE NAME T� Q CARE OF ADDRESS INFORMATION O <br /> cP—)N/ 7 Pam bo <br /> ADDRESS 2 NEAREST CROSS STREET ,,✓Bm i1tI D PARTNERSHIP ❑ STATE AGENCY <br /> L�O;IRPOAATIGN ❑ LOCAL-AGENCY ❑ fEXNA,AGENCY <br /> I� 19INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE ITH AREA CODE <br /> �2AcCA S"3 �L <br /> TYPE OF BUSINESS: ❑ 2 DIS UTOR ❑ 4 PROCESSOR -/Box If INDIAN EPA ID # <br /> RESE❑ I GASSTATION FARM ❑ 5 OTHER TRUSTVAT THIS <br /> LANDS ATION Dr ❑ SI 'l <br /> AT THIS SITE •!'— <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. N (LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> vMbo / kn/ T UI IL <br /> NIGHTS: NAME(LAST,FIRS ) PHONE If WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to ind,c.Ie ❑ PARTNERSHIP D STATE AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERALAGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> C <br /> MAILING or STREET ADDRESS ✓Box to ir,rlicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> D CORPORATION D LOCALAGENCY ❑ FEDERALAGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. IV 11. ❑ 111.❑ <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# AGENCY# FACILITY ID# #of TANKS at SITE <br /> I 1 14 10 14-o <br /> EM� <br /> FACIE. ID APPROVED BY NAME PHONE#WITH AREA CODE <br /> J'C)• PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> U,g1 AA,C,T# SUPERVISOR•DISTRICT CODE BUSINESS PLAN FILED DATE FILEDIx I T YES NO �IT 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 ONL'/('-� <br /> FORM A(3-2-88) \ <br /> • DATA PROCESSING COPY • J\ <br />