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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 FACILITY/SITE c9`i iOa."�P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT HANGE OF INFORMATION ❑ 7 PERMA YCLOSED SITE <br /> gr <br /> ONE ITEM E] 2 INTERIM PERMIT E] 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE z <br /> 10 <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> IV <br /> NEAREST CROSS STREET ✓Boelo indicate El PARTNERSHIP ClSiATf-AGENCI <br /> ADDRESS ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY ,4 <br /> [IC INDIVIDUAL ❑ COUNIVAGENCY , <br /> STATCA ZIP COu,� !1 S EPHONE WITH AREA CODE <br /> CITY NAME � h <br /> TYPE OF BUSW ESS: ❑ @ DISTRIBUT R ❑ 4 PROlifiS611 I ✓Box it INDIAN EPA ID N V #of TT'ANNK'K's <br /> RESERVATION ar 11AT THIS SITE <br /> ❑ 1 GASSTATION ❑ 3 FARM OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LASE FIRST) <br /> PdON5 N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE tt WITH AREA CODE <br /> /L <br /> NIGHTS. NAME(LAST,FlRST) <br /> PH N ITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME / CARE OFA RE-S INFORMATI N <br /> ING r STREET ADDRESS N/ D indicate ❑ PARTNERSHIP LlSTATE-AGENCY <br /> MAIL <br /> r �/ CORPORATION ClLOCAL-AGENCY [I FEDERAL AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CODE <br /> CITU NAME STATE ZIP CODE _ PHON�P.WI�AR <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME y! <br /> MAILING or STREET ADDRESS ✓Be.to In0lcalo ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE q,WITH AREA CODE <br /> CITY NAME <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. ❑ it. 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 N JURISDICTION x AGENCYIN FACILITY ID K N of TANKS at SITE <br /> 3 � � � Zvi 3 <br /> CURRENT LOCAL AGENCY ACI ITY ID k <br /> APPROVED BY NAME PHONE Al WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL, � PERMIT EXPIRATION DATE <br /> LOC TI CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESSPLAN FILED NO <br /> ❑ DAT <br /> ?. <br /> CH KA PER ITAMOUNT 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 ON <br /> ,V,I\/III FORMA(3-2-80) <br /> 0 DATA PROCESSING COPY 0 <br />