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STATE OF CALIFORNIP WATER RESOURCES CONTR00BOARD <br /> r'. <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAMo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 5 <br /> W <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) N <br /> F-L <br /> FACILITY/SITE NAME CARE OF ADDRESS INFO MATION <br /> Tear cu-0 SKS ST+�IH.t c_ Roles la 01 <br /> ADDRESS /l'��1 '/'�1/] yY n NEAREST CROSS STREET ✓3M to FNM 0 FABTNEBSHIP 0 STATEAGENCY <br /> 1 1 ( I ' a UL' 1 1 r-c_, ❑ CgUNtt AGENC!ION 0 LOC&AGENG( 11 RUEAALAGENCY <br /> CITY NAME STATE ZIP,6OSDE �O SITE PHONE N.WITH AREA CODE <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓80x if INDIAN EPA IID,N \�I <br /> ❑ I GAS STATION ❑3 FARM ❑5 OTHER TRUSTY <br /> LANDS or LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N 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 CARE OF ADDRESS INFOR ATION <br /> 0.(0 MR <br /> I L <br /> MAILING or STREET IPDRESS 1���//Y1--��n ✓$lu_lo indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 1 'c ' LJtix 3715_ 'LI CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STAT ZIP CE PHONE N,WITH AREA CODE <br /> OS 1_� �� lws- I <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,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. ❑ 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 /> COUNTY M JURISDICTION R AGENCY# FACILITY ID If If of TANKS at SITE <br /> c) I 1= a (o0 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE 0 WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATR C�DE CENSUS TRACT# SUPERVISOR-DI TRICT CODE BUSINESYP SN FILED NO ❑ DAT gD) �( <br /> CHECK#/`'J, PERMIT AMOUNT(njx\J SURCHARGE AMOUNT FEE CODE RECEIPT# BYY::_ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL <br /> FORM A(3-2-88} <br /> DATA PROCESSING COPY <br />