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STATE OF CALIFORNIV WATER RESOURCES CONTROL BOARD uj <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> RS -� <br /> ITE NAME 'L-D sNEARESTCROSSSTREET ✓�mloinOhmle ❑ PAATNEISUIP ❑ STATEAGENLY CAFPOUAL ❑ LOCA4A AGENN ❑ FE➢FAAL-AGBICI'/ 2 170 6 n ❑ INOMOUAL ❑ NE#.ITHFSC STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA / 6�lJ JSINESS 11 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID x N of TANK'# <br /> ❑ ❑ RESERVATION or ❑ ASTATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDSENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> ME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> ffNAME ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGEN ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE NWI <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED)CARE OF SS AT INFORMATION <br /> ENAME ✓Box toin0icale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ET ADDRESS ❑ CORPORATION ❑ LOCAL-AGENC ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL O COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N.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. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUEE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION M <br /> AGENCY M FACILITY ID N #of TA7SSITE3 PMONE N WI <br /> CURRENT LOCAL AGENCY FACILITY ID A S/ / <br /> APPROVED BY NAME <br /> PERMIT UMBER <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> BUSINESS PLAN FILED DATE FILED <br /> LOCATION CODE CENSUS TRACT# <br /> SUPERVISOR-DISTRICT CODE NO <br /> � , 73 2<< YES , <br /> CXR FEE CODE RECEIPT# BY: (l <br /> CHECK* PERMIT AMOUNT SURCHARGE AMOUNT <br /> 1 l <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM V APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. i <br /> FORM A(3-2-88) _ • \ <br /> ��s1 � <br />