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oe" <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM _ wa <br /> SITE 4�, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH ILITY/SITE -' <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ Z PER5dAIQ NTLY CLOSED SITE O <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE r S <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) W <br /> W <br /> FACILITY/SITE NAME Qn { CARE OF ADDRESS INFORMATION <br /> UJaRc� �- 6Ae CARS -/;lam \YI <br /> ADDRESS NEAREST CROSS STREET ✓Bm lo+dKak 0 PARTNERSHIP D STATE AGENLY <br /> �� ^ D CORPORATION Cl LOLL AGENCY 0 FEDERAL <br /> LA eej� /J 0 INOMom 0 WUNTf AGENCY <br /> CITY NAME STATEZIP DIE_ J SITE PHONE#.WITH AREA CODE <br /> CA - 5 C/J <br /> TYPE OF BUSINESS: ❑201STflIBUTOR ❑ 4PR0 SSOR EPA ID p <br /> RESERVATION or NOITAMSI <br /> ❑ 1 GAS STATION ❑ 3 FARM TH1:1ER TRUST LANDS AT THIS SITE '/lll <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) P ONE q_WLT REA CODE DAYS: NAME(I-AST,FIRST) PHONE#WITH AREA CODE <br /> T$dwand - a <br /> NIGHTS: NAME(LAST,FIRSPHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> T <br /> II. PROPERTY OWNER INF RMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ,/Box to indicate D PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADORES$INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY'A <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)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYA, JURISDICTION# AGENCY# FACILITY ID If If of TANKS at SITE <br /> D 10 i a 0 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE <br /> Pic 9, ? E <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIOg0 CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED / <br /> L/J 2 YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LE61)OR MORE TANK PERMIT FORM 'B'APPLICATION(S). LESS THIS ISA CHANGE OF SITE INFORMATION ONLY. V� <br /> 9M A(3-2-N) I\\ <br /> �1 DATA PROCESSING COPY �' <br />