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STATE OF CALIFORNS WATER RESOURCES CONTROBOARD <br /> �qG•'t�uurt�'l�f <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM a �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : a� o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °'�,.oa%`" <br /> MARK ONLY F-11 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE I-'a <br /> ONE ITEM ❑ 2 INTERIM PERMIT El AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00N <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) Cil <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS /� NEAREST CROSS STFEET ✓Bw loilgrale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> \ - �— _ s 1� ❑ CORPoPATION ❑ LOCAL AGENCY ❑ FFOERAL-AGEN(.}' <br /> �JL1LJ `J {/�a.\,-'J lw �VVV .g"IFpIVIOUAL ❑ COUNTYAGENCY <br /> CITYNA STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> 7ccq�- CA r,A`v <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 44PPROCESSOR ✓Box if INDIAN EPA ID a <br /> RESER❑ IF of TANK' <br /> ❑ 3 FARM Ej TRUSTTVLANDS ATION of ❑ <br /> 1 GAS STATION AT THIS SITE I <br /> THEfl <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(IAST,FIRST( PHONE if WITH AREA CODE <br /> 1 Y%AL, <br /> NIGHTS: NAME(I-AST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> �`S p z. <br /> MAILING o,STREET ADDRESS ✓Be.to Indicate Cl PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Com` <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION IF AGENCY# FACILITY ID If If of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> c <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRI CODE BUSINESS PLAN FILED DATE FILED `' <br /> a�W � ` Ll YES ❑ NO ❑ ,_) ' L <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT 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 INFORMATIONOIII. � <br /> FORM A(3-2-88) • �/ <br /> 0 <br /> DATA PROCESSING COPY <br />