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STATE OF CALIFORNIP WATER RESOURCES CONTROIBOARDOF <br /> A,• }/rF <br /> W <br /> { 1 <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE r <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 5� W <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CD <br /> FACILITY/SITE NAME ^ o S A CARE OF RE INFORMATION A A <br /> lilA-5 <br /> ADDRESS 533 NEAREST CROSS STRE``ETUU ✓Bm to immie ❑ PARTNERSHIP ❑ STATE AGENCY <br /> G.7 Q ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> LL�MIDUAL ❑ COUN7r`AGENCY <br /> CITY NAME O STATE Acs D q SITE PHONE p,WITH RREA CODE <br /> CA <br /> TYPE OF BUSINESS' ❑ 2 DISTRIBUTOR ❑ 4 PROCESSI ✓Boz If INDIAN EPA ID p <br /> #of TANK's <br /> RESERVATION or <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑'BOTHER TRUST LANDS ❑ AT THIS SITE O <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.FIRSTIL- PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> C ,� E <br /> MAILING or STREET ADDRESS 1 • • ✓Box to iridicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 15U <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCALAGENCYCl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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. ❑ it. [:] 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION# AGENCYIN FACILITY ID# If of TANKS at SITE <br /> 6022 OU <br /> CURRENT LOCALAGENCY FACILITY IDM APPROVED BY NAME PHONE a WITH AREA CODE <br /> 053 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Ou L419YES NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> C ' <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM V APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL� <br /> FORMA(3-2-8B) le DATA PROCESSING COPY <br />