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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> ° <br /> W <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �' Z <br /> �o <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE �"'°°°%�" <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENT ED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> jib <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) a <br /> FACILITY/ E AME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET an wiM ARTNEA,WIP ❑ STATE AGENCY <br /> ❑ CORPORATION LOCALAGENCY ❑ FEDERAL AGENCY <br /> ❑ INDIVIDUAL ❑ C01ND-AGENCY <br /> CITU NAME STATE ZIP CODE SITE PHONE q,WITH AREA CODE <br /> CA IUlYI-C— <br /> TYPE OF USINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR -/Box if INDIAN EPA 10 p <br /> 1'_.IT/ RESERVATION or k o1 TANK'N <br /> I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST IANDS ❑ AT THIS 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 /> FAME L61 CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS 5 / Y✓ / `� , ✓Car to indicate PARTNERSHIP ❑ STATEFEDERAL-AGENCY GENCY <br /> (rT DD 13 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE P ONE#,WITH AREA CODE <br /> C as i -o2.Lf <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I/BOX to indicate ❑ 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: 1. ❑ II. III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRU AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE <br /> = = = cif 3Y 00 1010 <br /> CURRENT LOCAL AGENCY FACILITY 10# _ APPROVED BT NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> j.� <br /> LOCATION CODE CENSUSTRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED _ -TE FILED 9 <br /> YES NO /r '— 9—/ 0 <br /> CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: <br /> C <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST 111 OR MORE TANK PERMIT FORM `BY APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. IN,FRAM A(3-20&1 <br /> \\/ �-b �' ~"DATA PROCESSING COPY -� <br /> I <br />