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• Zt�iY 0I+ 'Z <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> ` . . <br /> SITE /_ FACILITY/SITE, INFORMATION and/or P MIT APPLICATION a P <br /> L/ COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑fi TEMPORARY SITE CLOSURE 5� <br /> W <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) W <br /> FACILRY/SITE y�MEt / a CARE OF ADDRESS INFORMATION W <br /> / -5c0 uvrxbin Cri <br /> ✓ <br /> ADDRESS NEAREST CROSS STREET III x1We [IPAflTNE1BW ❑ SfA1EAGENCf <br /> CDNPORATION D LOCAL AGENCf D FEDERAL AGENCY <br /> / �5 T /��• ❑ INDYHII.W ❑ COtR TAGENCf <br /> CITY NAME / STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA gSdOf <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑N ESSOR ✓Box it INDIAN EPA IO N Y of TANK'# <br /> RESERVATION or1:1 AT THIS SITE <br /> ❑ I GASSTATION ❑3FARM L615 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAME(LAST.FIRST) PHONE II WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> /n c � <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> H. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> rC /naso <br /> ✓ indicate D PARTNERSHIP D STATE-AGENCY <br /> MAILING or STREET ADDRESS <br /> ORPOflATIOTION DLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> D INDIVIDUAL DCOUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> C'A oS on9 <br /> 111. TANK OWNER INFORMATION 8 ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> rrL2 s pcJn rs^ <br /> NERSHIP 0 STATE-AGENCY <br /> MAILING or STREET ADDRESS ✓ ORPORATION D 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. ❑ 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 N JURISDICTION It AGENCY N FACILITY ID M N of TANKS e1 SITE <br /> O o 0 / <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> E <br /> E CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> c) .3c33 YES � NO ��� 4 <br /> PERYITAYOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: <br /> C <br /> THIS FORM MUST BE ACCOMPANIED BY#(1)ORMORE TANK PERMIT FORM 'B'APPLICATI NLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> \ FORM A(3-2-88) <br /> .V�-/' DATA PROCESSING COPY <br />