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�OF <br /> STATE OF CALIFORNI9 WATER RESOURCES CONTRO 'BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> r <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION t <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ZIFpF?. <br /> MARK ONLY El NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION El7 PERMANENTLY CLOSED SITE F� <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURELIE Icy <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) C) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> RA P Q n1 VAiILUmG 0-D <br /> ADDRESS NEAREST CROSS STREET �yaocae LJPARTNERSHIP Q STATE-AGENCY <br /> 3G . 5-Tock..To K) 0 CGRPpRA710N 1-1LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INONIOUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> qq_ <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 P SSOR ✓Box if INDIAN EPA ID # #of TANK's <br /> OTHER RESERVATION or �/y AT THIS SITE <br /> ❑ 1 GAS STATION ❑ 3 FARM TRUST LANDS ❑ / v[I ►�� <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 /> L e� r <br /> NIGHTS: NAME(LAST,FIRST) PH04F It WITH AREA CODE NIGHTS_ NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> (Rien& _ M1tk) <br /> MAILING or STREET ADDRESS ✓EI ndicake ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> LP'CORPOHATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE HONE#,WITH AREA CODE <br /> l5 -q2,6`"1 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓f3ox to Ind case ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-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. FzrIII. ❑ <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# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE k WITH AREA CODE <br /> P6Iv 3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACCTT/k SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> V UL" i YES ❑ NO ❑ �jj <br /> CHECK# REKNIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k 9Y: <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), <br /> DATA PROCESSING COPY <br />