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_ T <br /> STATE OF CALIFORNI• WATER RESOURCES CONTROL ARD s` ^0 <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° ,; 1 0 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT [tKcHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 63 —4 <br /> J <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 4�a <br /> 0) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESSDn NEAREST CROSS STREET ✓Bulobaele 11PARTNER411P 11 STATE-AGENN <br /> O /�A I` 11 CORPORATION D LOCAL-A04M 1:1FEMIAL-AGEIC! <br /> a /-, D INDMOUAL D CO(AMAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE W TH AREA CODE <br /> C <br /> TYPE OF BUSINESS: ❑ 2 1611FOR ❑ 4 PROCESSOR I ✓Boxit INDIAN EPA ID # <br /> ❑ i GASSTATION FAflM ❑ 5 OTHER RESETRUST LANDS or If❑ ATtTHIIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS. ME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> x &flz' L v <br /> NIGHTS: NAME(LASI FIRST) PHONE#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 /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME (\ 4 CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,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. IV it. ❑ 111. ❑ <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 /> 10 1 U l ? (Q =0 CJ 1 / <br /> CURRENT LOCAL 4PENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER i/r1T PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIO CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# By <br /> LN 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 011ov <br /> FORMA(3-2-88) \\\\J <br /> DATA PROCESSING COPY <br />