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STATE OF CALIFORNO WATER RESOURCES CONTROBOARD ^" <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 ED4CHANGE OF INFORMATION ❑ 7 P IFN NTLY CLOSED SITE n <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE y U 1 a <br /> U <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME/ / / (- 1 IO / CARE OF ADDRESS INFORMATION <br /> ADDRESS �7 1/ y/ /V u• NEAREST CROSS STREET ✓Sm la xacale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> El�/-, .�/L-�O� f' 11INGRIVIWu E) CMTON 13 O NttA AGENCY <br /> FEDERAL <br /> CITY NAME STATE ZIP CODE SITE PHONE q,WITH AREA CODE <br /> T/2 CA <br /> ❑ <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR /PROCESSOR ✓Box it INDIAN EPA ID NESE <br /> Mol TANKY <br /> ❑ 1 GAS STATION ❑ 3 FARM F—] 5 OTHER TRUSTYATION LANDS or ❑ 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 9 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 INFORMATION <br /> MAILING or STREET ADDRESS ✓Box t°indi°ale 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCALAGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 9.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 Indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORAi'ION 0 LOCAL AGENCY 0 FEDERALAGENCY <br /> ❑ INDIVIDUAL 0 COUNTYAGENCY <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. ❑ 11. ❑ 111.❑ <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 11 IrrJURISDICTION If AGENCY# FACILITY ID M M of TANKS at SITE <br /> il. CURRENT LOCA/L AGENCY FACILITY ID N LIOVEIYONPA PHONE N WITH AREA CODE <br /> /�1572'S <br /> PERMIT NUMBER PERMIT APPROVAL DATEPIRATION DATE <br /> LOCATION CODE CENSUSTRACTR SUPERVISOR-DISPLAN FILED DATE FILED <br /> 1. .� ", 1, ES ❑ NOl� / <br /> CHECK# PERMIT AMOUNT SURCHARGE AMRECEIPT BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT FORM 'B'APPLICATION(S), UNLESS THIS,�HANGE OF SITE INFORMATION ONLY <br /> FORM A(3-2-88) / ` \ <br /> ��- \�j Ali <br /> DATA PROCESSING COPY <br />