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STATE OF CALIFORNIA` WATER RESOURCES CONTROL BOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -� <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ltl�5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 7j <br /> ONE ITEM ❑p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE a� <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> C� <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Puc,K <br /> A DRE$$ D NEAREST CROSS STR ET ✓9alortulle ❑ PARTNERSHIP ❑ STATE AGENCY <br /> �)j /�•L /� ❑ C/JRPoMLICN ❑ LOCA-AGENCY ❑ FEDEMLAGENCY <br /> V <br /> 'rig <br /> e ❑ NDNIMAL ❑ CDUNfY-AGENCI <br /> CITY NAME STATE ZIP CODE E PHONE 9.WITH AREA CODE <br /> CA ,;L <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID n <br /> ❑ If of TANICs <br /> 1 GAS STATION ❑ 3 FARM �OTHEA TRUSTMLANDS ATION of ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(FAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> GN ' - / <br /> NIGHTS: NAME(LAST,FIR T PHONE ITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> MAILING or ST EETAGORESA Box toiiftcale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> O Y ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMES_f ST9iE� ZIP CODE PHONE 9.WITH AREA CODE �O <br /> /\III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) C <br /> NAMES' CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to micale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME 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: I. ❑ 11. 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION R AGENCY# FACILITY ID# If of TANKS at SITE <br /> MI = = 10101l T a / I 1010101ql <br /> CURRENT LOCAL AGENCY FACILITY ID# APPRO BY lii PHONE M WITH AREA CODE <br /> bore3 <br /> PERMIT NUMBER PE MIT APP OVAL DATE PERMIT EILPIRATION D TE <br /> A13 `76 <br /> LOCATION CODE CENS 3 TRACT N UPE ISOR-DISTRICT CODE BUSINESS N FILE DATE FILED <br /> (�I 3 (dj 30L YES NO � <br /> CHECKM PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# Y: <br /> assassass <br /> I THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OPE TANK PERMIT FORM 'B'APPLICATION(S), UNLESSIS A CHANGE OF SITE INFORMATION ONL� <br />^V�nVI , ' <br /> 4 a3 <br /> 10 <br /> DATA PROCESSING COPY <br />