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45 <br /> STATI. OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> l <br /> FORM `A': y <br /> SITEUNDERGROUND STORAGE TANK PROGRAM V 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 <br /> ONE ITEM 7 PERMANENTLY CLOSED SITE r <br /> ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) �C / W <br /> FACILITY/SITE`AME �T O CRDRESS INFO <br /> E OF ADMATION <br /> Rw <br /> I1 �h, ��.4- - D,��,, �� nt <br /> ADDRESS_ ENCY <br /> 1/.'��,1 A� NEARE O(7OSSSTREET ✓lax it indole ❑ PARTNERSHIP <br /> \ , V \ I'CJ PoRATION ❑ LOCALAGENLY ❑ AGENCY <br /> CITY NAM ❑ INGIYIGUAL ❑ COUNTY WITH <br /> A <br /> STAT ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA ()q Ll —I <br /> TYPE OF BUSINESS: ❑ 1 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID It <br /> ❑ I GAS STATION ❑3 FARM Ei�nTHER 7pUSRYIANDS or <br /> ❑ N of TANK's <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NA (LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Q V ^d n ao -1--1 ) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) V PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> ,^^ oo PHONE k WITH AREA CODE <br /> �Y__•ww� 0 u(j <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS -/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> . STATE ZIP CODE PHONE p,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I/Box toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME <br /> STATE ZIP CODE PHONE p,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. <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) DATE <br /> LOCAL AGENCY USE ONLY <br /> C.00UTNT/TYYY# JURISDICTION N AGENCYA, FACILITY IDN N of TANKS at SITE <br /> CURRENT LOCAL NCYFACILITY IDN APPROVED BY NAME <br /> /_ (J' C ' PHONE N WITH AREA CODE <br /> PERMIT NUMBER lJ 1�J PPEERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT�N \ SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> `� . O V moi ' D YES NO l.� - <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N <br /> 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(31 <br /> 0 DATA PROCESSING COPY AD I <br />