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STATE OF CALIFORNm WATER RESOURCES CONTRM BOARD <br /> FORM 'A': <br /> SITE FACUNDERGROUND STORAGE TANK PROGRAM <br /> MARK <br /> DT <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> J. COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> OONLY <br /> ❑ ) NEW PERMIT ❑ 3 RENEWAL PERMIT <br /> ONE ITEM F1 2 INTERIM PERMIT ❑5 CHANGE OF INFORMATION <br /> ❑4 AMENDEDPERMIT ❑e TEMPORARY SITE CLOSURE PERMANENTLY CLOSED S, <br /> 1. FACILITY/SITE INFORMATION&ADDRESS— <br /> FACIL^ I�ITE N „ (MUST BE COMPLETED) <br /> J oo kr s o rl CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> S NEAREST CROSS STREET /BMW A No <br /> CITY NAME _-/ DDRPLYi471 11 LOCAL <br /> AGNIP ❑ GiAiEAGENLY <br /> �C NOM AL AGEN ❑ FEDERA.AGEN <br /> A STATE � CWNIYAGENLY <br /> COD SvEPH EN WITH COD <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑4 PROCESSOR ✓BOX if INDIAN EPA ID NA Z YO ��/O <br /> ❑ I GAS STATION 3 FARM ❑5 OTHER RESERVATION or ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) TRUST LANDS Nof TANK's AT THIS SITE <br /> DAYS: NAME(LAST FIRST) EMERGENCYCONTACT PERSON(SECONDARY) <br /> Q O� (p� PHONE Al WITH AREA CODE DAYS�NgME(LA$ FlRST) <br /> KI�AJ _ 7 K 1-_/ PHONE p WITH AREA CODE <br /> N MTS: "ME(LAST,F/I�RNPHONE WITH AR CODE NIGHTS: NAME ST,FIRST) <br /> �9W PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFOR Ale <br /> NAME ION&ADDRESS— (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS <br /> ✓Box to indicate ❑ pgRTNEggHlp <br /> CORPORATION ❑ STATE-AGENCY <br /> ❑ ❑ LOCAL-AGENCY ❑ F <br /> CITY NAME EJ INDIVIDUAL ❑ COUNTY-AGENCY EDERAL-AGENCY <br /> STATE ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> AS- <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS-� <br /> ✓Boz to inchoate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FE <br /> CRY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY DERAL-AGENCY <br /> STATE ZIP CODE PHONE p,WITH AREA 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 11. <br /> ❑ 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) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION X AGENCY R FACILITY ID N <br /> B Of TANKS h SITE <br /> Oo � z � oo <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME <br /> PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE - PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACTN SUPERVISOR-DISTRIC BUSINESS PLAN FILED DATE ILED <br /> 32-0 YES El NO 0 ( (f u) <br /> CNECKM PERMIT AMOUNT SU C. <br /> GE AMOUNT FEE CODE RECEIPTN <br /> BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONIS), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> /FORMA(3-2-88) <br /> DATA PROCESSING COPY /J <br />