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/itl y'�Ol i�:rM1f• <br /> STATE OF CALIFORNO WATER RESOURCES CONTRO BOARD r <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> _ m Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �y I c <br /> C'4lIFOPN\P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PER TLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE IV N <br /> CD <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) -I <br /> F <br /> ACILITY/SIT <br /> ME CARE OF ADDRESS INFORMATION <br /> NEAREST CROSS STREET ✓Ro�lo inOWc 0 PARTNERSHIP 0 STATE AGENCY <br /> n ❑ CORPORATION ❑ LOCk AGENCY ❑ FEDERAL AGENCY <br /> N. Q. ❑ INDNIDU" ❑ CCIINTKAGENGY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> Sto Ci l���Yu CA <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID If q of TANK'a <br /> �j; /OT'HER RESERVATION or ❑ /'1 14�/ i _ AT THIS SITE <br /> ❑ 1 GAS STATION ❑ 3 FARM L{d� TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE p WITH AREA CODE <br /> NIGHTS'. NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE It WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓BON to intlicate 0 PARTNERSHIP Cl STATE AGENCY <br /> ❑ CORPORATION 0 LOCALAGENCY0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING Or STREET ADDRESS ✓Bax to intlicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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. El if. ❑ III. El <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 If #of TANKS at SITE <br /> OF61 W71S7 400 <br /> CURREN OCAL AGEN Y FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> O PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> PERMIT NUMBER <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED NO ❑ DATEFI,ED <br /> 3 . 1 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLLY <br /> FORM A(3-2-88) <br /> ^ DATA PROCESSING COPY J <br />