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STATE OF CALIFORNN WATER RESOURCES CONTROBOARD �SEP`EF, <br /> \SA <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Fo -� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 115-3- <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE 0 DDRESS INFORMATION <br /> 5 m a h c �00-a Vats <br /> ADDRESS _ NEAREST CROSS STREET ��✓,�B�.1o�indicate ❑ PARTNERSHIP ElSTATE-AGENCY <br /> ^�'L� !� t_TOORPORATION 1:1LOCAL-AGENCY E] FEDERAL-AGENCY <br /> l.i /J ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> ( c '`� CA Salo � 0jA TYPE of BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> 99 <br /> ❑ TANK It <br /> 1 GAS STATION ❑ 3 FARM 0-5-OTHER (p 111 4 111 <br /> TRUST LANDS ATION�l ❑ of HIS SITE <br /> T THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: AME(LAST,FIRST) PHONE# #WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE WITH AREA CODE . <br /> �a-� <br /> NIGHTS: NAME(LAST,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 /> r"9 <br /> to —\ <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE rNE�ITHREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> L_)a� <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ZI 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> EEI FcT) 6 I I I y I TR I c I o FcTol <br /> CURRENT LOCAL AGENCY FACILITY ID Jr 115 Q��-� APPROVED BY NAME PHONE#WITH AREA CODE <br /> � � <br /> PERMIT NUMBER __TPERMIT APPROVAL DATE PERMIT EXPIR ION DATE <br /> ::�:l <br /> LOCATIO(NN CODE CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS LAN FILED DATE FILED j <br /> s 1;t1 YES ❑ NO ❑ c� I-!Tc�C I <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: <br /> ii <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 /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />