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STATE OF CALIFORNIN WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM ="5fn 4 M• <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONto <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE '`'!_ Y- ' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F-J, <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 4 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) Ca <br /> O <br /> FACILITY/SITE NAMEy5 �' CARE OF ADDRESS INFORMATION <br /> -fhzzM '�� <br /> ADDRESS 57"5-1 ep(/( E N El STREET ✓Ao,m Nrap GARTNERSNIP El STATE AGENCY <br /> . ❑ CORPORATION ❑ LOCAL <br /> El FEDERAL AGENCY <br /> /,A Y C/ �••p��p� ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONEY WITH AREA COD <br /> S��Go✓ CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCEBSOfl ✓Box if INDIAN EPA ID p K al TANK's <br /> ❑ 1 GAS STATION 3 FARM 5 OTHER RESERVATION or AT THIS SITE <br /> ❑ ❑ TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST)) PHONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE CIF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box toinbcale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ 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 lointlicale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION M AGENCY A FACILITY ID K If of TANKS at SITE <br /> CURRENT LOCAL AG CY FACILITY IO N APPROVED BY NAME PHONE 0 WITH AREA CODE <br /> AN <br /> os <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> ODE CENSUS TRACT F SUPERVISOA-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> 1p F / YES ❑ NO PERMIT AMOUNT SURCHARGE A OUNT FEE CODE RECEIPT 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 INFORMATIONN^OttLY. <br /> FORM A(3-2-88) rI <br /> • <br /> s-'\0 * DATA PROCESSING COPY `,� <br />