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STATE OF CALIFORA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM = " " <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FA ITY/SITE <br /> MARK ONLY F 1 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 1--& <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0 —4 <br /> )..a <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) v <br /> Ln <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> /W cSGt/rS <br /> ADDRESS NEAREST CROSS STREET ✓Box lomitele PARTNERMHIP ❑ STATE-AGENCY <br /> ❑ fA ❑ LOCAL AGENCY 13FEDERAL AGENCY <br /> _ IVIOOAL 11 WUNIRAGENCY <br /> CITY NAME STATESITE PHONE p,WITH AREA CODE <br /> ZIP CODE <br /> « . CA dao yb <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑4 P R ✓Box if INDIAN EPA ID It <br /> ❑ I GASSTATION ❑ 3 FARM 5 OTHER TRUSTYLANDS or ❑ /Y3 AT THIS SITE / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE k WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> L ��5 S //�. Cav> l -S 6� c00%/ ✓/�� FG/_e &62tV <br /> -�ai <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE' NIGHTS'. NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> S <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boxt tate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ PPOORRAATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> INL7 DIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to in ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ RATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,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 k JURISDICTION R AGENCY M FACILITY ID R R o1 TANKS at SITE <br /> 3 a 3 y s L v i <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE <br /> BALL <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECKO <br /> E CENSUS 2 TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> lr� YES NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k 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 ONLY. <br /> IFORM A(3NBB) <br /> 1 t �1\ DATA PROCESSING COPY .x, <br />