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µ <br /> • �OF'.. <br /> STATE OF CALIFORNI1P WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION > ` 0 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Cq�!FORN'p,P <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE Z <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ZSK f&/ <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> o c-a/Scan c J!^, Qj <br /> ADDRESS NEAREST CROSS STREET ✓Boz to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ C N ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA 76-36, <br /> TYPE OF BUSINESS: ❑ 2 D IBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS ATION 0f ❑ / #of TANK's <br /> u`�. ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHON #WITH ARE CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME( ST,FIRST) PHNE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> Sc?/mom-'E" !&./'!G"_. <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> �r <br /> MAILING or STREET ADDRESS ✓Boxndicate ❑ PARTNERSHIP 13STATE-AGENCY <br /> RPC ATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box Thicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ RPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <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. II. ❑ 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# JURISDICTION# AGENCY# FACILITY ID—_#-, I #of TANKS at SITE <br /> C NT, AL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> e-\ CA <br /> PERMIT NUMB ATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED —7 <br /> ATE FILED <br /> s J� 3 o�oZ 02 ( YES [_ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT EE FCODE RECEIPT# <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1 R MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />