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STATE OF CALIFORRA WATER RESOURCES COAL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> O <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE >d; <br /> o N,P <br /> FM <br /> ARK ONLY ❑ ( NEW PERMIT 3 RENEWAL PERMIT <br /> ONE ONLY <br /> 5 CHANGE OF INFORMATION ) PERMANENTLY CLOSED SITE <br /> 2 INTERIM PERMIT 4 AMENDED PERMIT <br /> I. FACILITY/SITE INFORMATION & ADDRESS - O 6 TEMPORARY SITE CLOSURE <br /> (MUST BE CO <br /> FACILITY/SITE NAME COMPLETED) <br /> PAS CARE OF ADDRESS INFORMATION <br /> ADDRESS 1L <br /> G �U[Ii5 1 <br /> �. �. NEAREST ClTN <br /> CROS STREET ✓Boxro Mint PAERSHIP <br /> CITY NAME �" d� ❑ COR'OIUTION ❑ LOGILASENGY ❑ FEDERAL AGENCY <br /> ❑ <br /> STATE INDNIOIIAL ❑ 'rv. Y-AEN LY <br /> ZIP CODE <br /> SITE PHONE p,WITH AREA CODE <br /> TYPE OF BUSINESS: p DISigIBUTOR �4 PROCESSOR ✓Box if INDIAN EPA ID aA <br /> ❑ I GAS STATION LYS FARM 0 5 OTHER RESERVATION or <br /> TRUST LANDS ❑ M of TANK's <br /> EMERGENCY CONTACT PERSON(PRIMARY) AT THIS SITE r <br /> DAYSNAME(LAST,FIRST) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHONE N WITH AREA CODE r� DAYS: NAME(LAST,FIRST)9rf —�f +',7 PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) f PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME <br /> t� I_ S CARE OF ADDRE55INFORMATION <br /> MAILING or STRE ADDRESSO Gf� <br /> °� �' ✓Box toiadicate ❑ PARTNERSHIP <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑El <br /> FEDERALSTATE-AGENCY AGENCY <br /> ClITY NAME INDIVIDUAL 11COUNTY-AGENCY <br /> STATE ZIP CODE <br /> h% PHONE p,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADORES <br /> ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE If.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: 1. II. 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&SIGNATUREI <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION M AGENCY Rcl <br /> P of TANKS at SITE •, <br /> 7 � r <br /> CURRENT LOCAL AGENCY FACILITY ID M <br /> 1 APPROVED BY NAME PHONE N WITH AR CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT NSUPERVISOR-D187111CT CODE <br /> BUSINESS PLAN FILED DATE FRED <br /> .27 3- 4., � � �� YES NO <br /> CNEC N PERMIT AMOUNT <br /> SURCHARGE AMOUNT �f <br /> FEE CODE RECEIPTN <br /> Y. <br /> THIS FOAM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM <br /> ' ' <br /> FORMA(3-RM APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> 0 �� <br />