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STATE OF CALIFORNO WATER RESOURCES CONTRO BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM o Z <br /> SIT i FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> I NEW PERMIT F—] 3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION ❑ 7 PERM LOSED SITE <br /> MARK ONLY <br /> ONE ITEM ❑ 2 INTERIM PERMIT ID4 AMENDED PERMIT E] fi TEMPORARY SITE CLOSURE Q <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) cn <br /> FA LIN/SITE NAM CARE OFADDRESS INFORMATION <br /> �j a Qom, L mr N 4 <br /> ADDRESS NE[REST CROSS STREET ✓9alb vdirale ❑ PARTNERSHIP ❑ SEDENAGENGY <br /> '� /[� DOflP0"A ❑ LOCA AGENCY <br /> ❑ FEDEPALAGENCI <br /> 0 INDNIDUAL D COUNTY-AGENCY <br /> CITY NAME I / j STAT^A ZIP DE SITE PHONE N,WITH AREA CODE <br /> f u <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR '.4 PROCESSOR ✓ x if INDIAN EPA ID n #of TANK•N <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTVLANDS or ❑ W A AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHO/ N WITH AREA CODE <br /> S� <br /> NIGHTS' NAM LAST,FIRST) PHONE N WITH AREA CODE NIGHT NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> -d7 z_1 .A <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME S (/-.ECARE O ADDRESS INFORMATION <br /> MAILINGor S(TRE`E_TADDRESS B� indicate ❑ PARTNERSHIP Cl STATEAGENCY <br /> ORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> / D INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME/ •,may- STATE ZIP CODE PHONEN 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 Iodoate D PARTNERSHIP Cl STATE AGENCY <br /> Cl CORPORATION Cl LOCAL-AGENCY D FEDERAL AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. R1, III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION # FACILITY ID# #of TANKS at SITE <br /> O <br /> D � f n o t <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAM PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL ATE^ PE MITE IRA ON DATE <br /> l <br /> LCHEC <br /> CATION CODE CENSUS TRAI6Th SUPER ISOR-O STRICT CODE BUSINESSPLAN FILED NO DATE FILED <br /> `OV <br /> N 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 ON <br /> ` \FORM A(3-2-88) . \J <br /> DATA PROCESSING COPY <br />