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STATE OF CALIFORNIA WATER RESOURCES CO • <br /> NTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICZ <br /> ATION 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El 7 PERMANENTLY LOSEO SITE F-+ <br /> ONE ITEM p INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �I <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) O <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 6 u 14---- <br /> ADDRESS U NEA REST CROSS STREET ✓BNI01Ip1 ' ❑ PARTNERSHIP Cl STATE AGENCY <br /> i I 1� __ ❑ IDN ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> IiL LJ`� DIVIpUA, ❑ COUNTRAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE It.WITH AREA CODE <br /> CA rlsayo �(c- <br /> TYPE OF BUSINESS: p IRUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> T GAS STATION L-K3 FARM 5 OTHER RESERVATION or ❑ / /c_ AT TANK'S / <br /> TRUST LANDS (/C G AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAS/T,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CC CARE OF ADDRESS INFORMATION <br /> J <br /> MAILING or STREET ADDRESS ✓Box toInd le 11 PARTNERSHIP 1:1 STATE-AGENCY <br /> ❑ C ATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> U�NDIVIDUAL ❑ COUNTYAGENCYCITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S/ --,c <br /> MAILING or STREET ADDRESS ✓So.I olcate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ PORATION Cl LOCAL-AGENCY ❑ FEDERALAGENCY <br /> CITY NAME <br /> NDIVIDUAL 11COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N,WITH AgEA 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: L ❑ 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 A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYIN JURISDICTION If AGENCYIN FACILITY ID If #of TANKS at SITE <br /> aDU ovc) i <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> i5KEtV/� <br /> PERMIT NUMBER PERMITAPPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3 3 YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# By; O <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 ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />