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or^^� <br /> 5,�\Y„w•� T�f <br /> STATE OF CALIFORNIP WATER RESOURCES CONTRO OARD V .A <br /> A, <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE C�FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION mom e <br /> COMPLETE THIS FORM FOR EAC!-FACILITY/SITE <br /> F-1 F-11 NEW PERMIT 3 RENEWAL PERMIT El CHANGE OF INFORMATION 7 PERMANENT <br /> MARK ONLY LY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT <br /> El 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> 0 CARE OF ADDRESS INFORMATION <br /> FACILITY/SITE NAME <br /> GA NEAREST CROSS STREET ✓B.WxdxAR 0 PWTNB91P STATE AGENp <br /> ADDRESS ,A 0 CORPORATION 0 LOCALAGENCY 0 FEDERALAGENCY <br /> S C(NG El <br /> INDWIDUAL 0 COUNTYAGENCY <br /> STATE CZIP SITE PHO=E p,WITH AREAEDE <br /> CIN A SYS NAME q/ 3/ <br /> AV EPA ID p Nof TANKN <br /> TYPE OF BUSINESS'. ❑2 DISTRIBUTOR ❑ A PROCESSOfl ✓Box it INDIAN <br /> RESERVATION or AT THIS SITE <br /> ❑ I GAS STATION ❑3 FARM �,OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. �� FIRST) I AA PONE p WITH <br /> �AjREA CODE DAYS NAME(IAS44 <br /> FIRST) <br /> PHONE M WITH AREA CODE <br /> T'.i(�C, ' I�/� PHONEp WITH AREA CODE <br /> NIGHTS'. NAME(LAST.FIRST PHONE p WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> Su-P�e t <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BEffORATION <br /> COMPLETEDRESS D) <br /> CARE OF[NAME ^ Indicate ❑ PARTNERSHIP STATE-AGENCY <br /> NG or STREET ADDRESS ( N 0 LOCAL-AGENCYFEDERAL-AGENCY <br /> DUAL ZIP ODECCOUNTY-AGENPHONEaITH AREA CODNAME 1 ZO111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COOMCARE OF ADDRESS INFORMATION <br /> NAME <br /> as Z <br /> ✓Box to intlicale [:1 PARTNERSHIP CSTATE-AGENCY <br /> MAILING or STREET ADDRESS 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> STATE ZIP CODE PHONE M.WITH AREA CODE <br /> CITU NAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH AB011S ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. El III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> onrE <br /> APPLICANT'S NAME(PRINTED A SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> FACILITY ID R B of TANKS Bl SITE <br /> COUNTY N JURISDICTION R AGENCY M 0 � D <br /> � o <br /> CURRENT LOCAL AGENCY FACILITY IDN <br /> APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER <br /> PERMIT APPROVAL DATE PERMR EXPIRATION DATE <br /> DATE FILED <br /> LOCATIONCODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED NO � � <br /> 2 0YES <br /> CHECK• PERMIT AMOUNT SURCHARGE AYOUMT <br /> FEE CODE RECEIPT N BY: r <br /> TMS (/�-� <br /> FORM MUST BE ACCOMPANIED BY AT LEAS OR MORE TANK PERMIT FORM'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY./ <br /> / FORMA(3-2-88) j <br /> JI // <br />