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STATE OF CALIFORNwd WATER RESOURCES CONTROL BOARD <br /> yt��. rM1e <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> 1^„ '" <br /> SITE )I „ I FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> li COMPLETE THIS FORM FOR EACH FACILITY/SITE oa_ <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Fk5 CHANGE OF INFORMATION ❑ 7 P TLY SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S3 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 7� 10 <br /> FACII}//cc;SAM CARE Of JDDRESS INFORMATION <br /> ADDRESS �� �• Isa <br /> NEARNT CROSS STREET ✓BIA loiMica 0 I'MINERSHI O❑ STATE AGENCY <br /> l 3 /dt "d R °❑ INDIVIDUAL O LOCAL-AGENCY Nui x <br /> CITU y[�ME STATE �(]��/7p CODE SITE P NE N.WITH AREA CODE rfijW <br /> TYPE O'FfBUSINESS. CA 52,t� `13� -wol <br /> ❑2 DISTRIBUTOR ❑ OF OR ✓Box if INDIAN EPA ID a <br /> ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST RESEVATION LANDS or ❑ AT THIS SITE N o1 TANK's <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMER ENCY CONTACT PERSON(SECONDARY) <br /> OA - NAME( T,FIRST) HONE N WITH AREA CODE DAYS N E(LAST,FIRST) PHO N WITH AREA CODE <br /> �� -grot A S % <br /> NIGHTS E(LAST,FIRST)) - PHONE N WITH AREA CODE NIGHTS NAME(LAST,FIRST) P NE N WITH AREA CODE <br /> 2,o /—ilwl S /16 S <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF AD SS INFORMATION <br /> A <br /> MAILING r STREET ADDRESS ✓Bo to indicate 13 PARTNERSHIP Cl STATE-AGENCY <br /> SI/'�� ❑ CORPORATION 0 LOCAL-AGENCY DER -AGENCY <br /> ❑ INDIVIDUAL 0 OOUNTY-AGENCV <br /> Cltt NAM STAT! ZIP E PHpJ p,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) J\ <br /> NAMEGA ADDRESS INFORMATION <br /> S 1A <br /> MAILINGnr T EET ADDRESS I/Box to intlicaie Ll PARTNERSHIP Cl STATE-AGENCY <br /> l\ LlCORPORATION ❑ LOCAL-AGENCY ❑ F RA - GENCY <br /> 0 INDIVIDUAL 0 COUNTY AGENCY <br /> CITY NAME ST5 I ZIP CQD PHONE# ITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> Jl <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYII JURISDICTION If AGENCY N FACILITY ID k R o1 TANKS BI SITE <br /> O 101 241 Z k 1 61 b 1 D 10 <br /> CUR T LOCAL AGENCY FACILITY IDN p NOE PHONE M WITH AREA CODE <br /> u /o <br /> PERMIT NUMBER PERMIT APPROVAL DATE I EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERV OR-DISTRICT CODE BUSINESS PLAN FILED DAT FIL �I,(� <br /> b r YES NO f v� <br /> CHEC N PERMIT AMOUNT SURCHARGE AMOUNT FEE,CODE RECEIPTN Y: <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 /> IJ•../ DATA PROCESSING COPY a./ <br />