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STATE OF CALIFORNIP WATER RESOURCES CONTROL BOARD `^?a <br /> e <br /> FORM A: <br /> UNDERGROUND STORAGE TANK PROGRAMo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I a <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE ""Forcle"'" <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I'A' <br /> ONE ITEM ❑ 2INTERIM PERMIT El AMENDED PERMIT El TEMPORARY SITE CLOSURE 6J C" <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) "J <br /> W <br /> FACILI /SITE NAME CARE OF ADDRESS INFORMATION <br /> ohN pvt�-�o <br /> ADDRESS NEAREST CROSS STREET ✓Bwloiigirale ❑ PARINEFSHIP ❑ STATE AGENCY <br /> pfs c o f El CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> J ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITU N ME STATE P CODE SITE PHONE#,WITH AREA CODE <br /> ,v Cot CA 533 6 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4PROCESSOR -/Box if INDIAN EPA IDR <br /> RESEIf TANKY <br /> ❑ I GAS STATION FARM ❑ 5 OTHER TRUSTVLANDS ATION of ❑ AT THIB SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAM45, CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE x,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME /� CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ❑ I. ❑ 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# JURISDICTION Al AGENCY# FACILITY ID If #of TANKS at SITE <br /> 1 �/ q1 101010111 <br /> CURRENT LOCAL A NCY FACILITY ID N# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER f17,�j/ fG� PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHE <br /> CATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO 4h75 <br /> # PERMITAMOUNT 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 INFORMATION ONLY. <br /> FORM A(3-2-88) _S <br /> 0 DATA PROCESSING COPY <br />