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STATE OF CALIFOR A <br /> WATER RESOURCES CONTROT0 BOARD Ski <br /> L <br /> FORM 'A': I UNbtAGROUND STORAGE TANK PROGRAM <br /> SITE 1 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F LITY/SITE <br /> L1€GRN <br /> =MARKONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL©SED SITE <br /> ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED' <br /> � N <br /> FACILITY/SITE NAME Q <br /> CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> h p / - NEAREST CROSS STREET ✓3w to n?icale U P+*TKPSHIP EJSTATE AGENT' <br /> G ��G,'i � �j'�,- J _ ❑ CORPORATION 010CAL.AGENCY ❑ FEDERALAGENCY <br /> CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> fr� Cc�z <br /> CA _� <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ d ESSOR ✓ <br /> Box ii INDIAN EPA la a <br /> Fl GAS STATION F-13 FARM 5 OTHER RESERVATION or ❑ #of TANK's <br /> TRUST LANDS AT THIS SITE c L <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE q WITH AREA COPE <br /> an f oz0> <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAMEF <br /> LAST,FIRST) <br /> - ( ) PHONE N WITH AREA CODE <br /> il. PROPER Y OWNER INF RMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> -Scr r+1P ? <br /> MAILING or STREET ADDRESS Box io ,� bNFRSHIP 13 STATE-AGENCY <br /> �.+.�n,' <br /> El CORPORATION ❑ayLOCAL AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE q,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS-- (MUST BE COMPLETED) <br /> I NAME <br /> -.)Cr ��� CS CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box 10 indicate ❑I?kRTNERSHIP <br /> ❑ CORPORATION [j' 11 STATE-AGENCY❑ FEDERALAGEN- GFN <br /> CY <br /> CITY NAME <br /> INDIVIDUAL Ll COUNTY AGENCY STATE ZIP CODE <br /> PHONE 11,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE�I)BO%INpICATINl3 WNICK ABOVE ADORE$$SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. . <br /> ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> I APPLICANT'S NAME(PRINTED,L SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> [PIR <br /> TY* JURISDICTION N AGENCY S I= -,'''',= FACILITY ID N <br /> M of TANKS at SITE <br /> IEEE= <br /> E=_ <br /> CAL AGENCY FACILITY ID N APPROVED BY NAME <br /> PHONE N WITH AREA CODE <br /> BER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> ODE CENSUSTRACTO SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> PERMIT AMOUNT YES ❑ NO ❑ � <br /> SURCHARGE AMOUNT FEE CODE RECEIPT II <br /> BY: <br /> C G <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1 MORE TANK PERMIT FORM 'B'APPLICATION(S), UN Ie THIS IS A t'" GE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-68) <br /> PROCESSING COPY <br />