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• or^ <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION . <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PER NENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE Ngh/E/ CARE OF ADDRESS INFORMATION <br /> �7 � 7STATE <br /> EST CROSS STREET ✓Bov wWTIO 0 PAWNLOCAL RSHIPAGENCY <br /> 0 STAFEDERAL <br /> AGENCY <br /> AGENCY ADDRESS / L 0 0 CLNPpPJ,PON 0 00AN7 AGENCY ❑ FEUERAI AGENCY <br /> ❑ INBIV1WAl ❑ CGUNry AGENC! <br /> CITY NAME NN ^ CA Z �FSITE PHONE A.WITH AREA CODE <br /> /vl <br /> TYPE OF BUSINESS'. ❑2 DISTRIBUTOR ❑ /PROCESSOR ✓Box if INDIAN EPA ID a N of TANK'F <br /> RESERVATION or ❑ O <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(�FIR T) rl / PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> /mr�7/_ // I�3G/ 2 Z Ii/O <br /> NIGHTS: NAME(LAST. RST) PHONE a WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> 11. PROPERTY 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 /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> Cl INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to,ndicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> [I CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE If,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: 1. E] 11. ❑ III.E] <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 N JURISDICTION N AGENCY N FACILITY ID R N of TANKS at SITE " <br /> FFP3 <br /> CURRENT LOCAL AGEI FACILITY ID a BY NAME PHONE N WITH AREA CODE <br /> vLL.z i tSUPERVIO <br /> PERMIT NUMBER PPPROVAL DPERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT NBUSINESS PLAN FILED DATE FILED <br /> C7 9 c2 -z ? ? YESE] NO <br /> CHECK M PERMIT AMOUNTSURCHACODE RECEIPT N BY: <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 /> FORM A(3-2-88) • <br /> -3,\)-- <br />