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S <br /> STATE OF CALIFORNIN WATER RESOURCES CONTR BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM 4 <br /> SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , 1 <br /> 4�iORN�% <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE E tl <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> R'MEITE NAME <br /> 7 <br /> a C �f�CTT C9wicale N NEAREST CROSS STREET ✓ Oto inRATIO ❑ LOCAL AGEN ❑ FEDERAAGENS O U ® w wAPOUAL ❑ COUNV AEx ❑ FEOEA LAcexaD ❑ IrvolvlounL ❑ NE# ITHGUNA STATE ZIP DE SITE PHONE N,WITH AREA CODE fio K �-( CA 5Aa Cao 5163- 71(, <br /> USINESS ❑ 2DISTRIBUTOR ❑ 4PROCESSOR ✓Box iI INDIAN EPA ID a #of TANK'sRESERVATION or ❑ AT THIS SITESSTATION ❑ 3 FARM ❑ 5 OTHER TRUSTLANDSENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> AME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NA ME(LAST,FI RST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAM <br /> e'er olntlicale ❑ PARTNERSHIP ❑ STATE-PGENCV <br /> MAILING or STREET ADDRESS �T ['' CORPORATION ❑ LOCAL-AGENOV ❑ FEDERAL-AGENCY <br /> / x )r ' In ' �] t-x ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> DE <br /> CITY NAME (/(J ///Itt�111 STATE � ZIP <br /> 3x 3 0 200_' ,HAREAA 0 <br /> 2 2 <br /> � l/�D Ol <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> 6z yr 4S c owher <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY <br /> AGE ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> STATE ZIP CODE PHONE p,WITH RHEA CODE <br /> CITY NAME <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 /> DATE <br /> APPLICANT'S NAME(PRINTED d SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> FACILITY IDM M of TANKS at SITE <br /> CO NTYM JURISDICTION <br /> � AGEIi <br /> OK/ O Q O <br /> CURRENT LOCAL AGENCY FACILITY ID# <br /> APPROVED BY NAME PHONE M WITH AREA CODE <br /> Bga ep.3 <br /> PERMIT NUMBER <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRIC CODE BUSINESS PUN FILED DATE FILED <br /> 0 �3 f YES NO <br /> 2a ❑RECEIPT# BY: <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <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) 0 <br /> DATA PROCESSING COPY J <br />