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✓j,L d r�".. <br /> STATE OF CALIFOR A WATER RESOURCES CON#OL BOARD <br /> FORM `A': � 1m <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION h <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE c 1 <br /> R{1FOR��P <br /> MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFOHMATION El7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I cro <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) p <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> " 714A)�n 4& <br /> ADDRESS G_ _ ,(/f /J/�jJ NEAREST CROSS STREET ✓El Bax tointlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ✓ 4 , / ' �"+'CMC_- ❑ NDIVIDUAALIQN ❑ COUANTY AGENCY ❑ fEOEAAL-AGENCY <br /> CITY NAMESTATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> /O['/O /� CA <br /> TYPE OF BUSINESS. ❑ p DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATEON or #of TANK'n <br /> ❑ 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS', NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAfiE(LAST, IRST) 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 /> MAIL{NG or STREET ADDRESS ✓Box 10 indicate Q PARTNERSHIP ❑ STATE-AGENCY <br /> !� �j ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> /. !J `B-YNDIVIDUAL ❑ COLINTY•AGENCY <br /> CITY NAMEc1r_5 STATE ZIP CODE <br /> PHONE#,WITH AREA CODE <br /> 1 <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ' <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE Y,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: L ❑ If. ill. ❑ <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 B SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# �Y�C�a #of TANKS at SITE <br /> �J_ I L Ll E I I a I � I (o 1 ,61 1 1 1 h:�- <br /> CURRENT LOCA AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> Ls �3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL D <br /> c 32-3 2 O 3 YES ❑ NO ❑ �: L Q <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST r"OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL <br /> DATA PROCESSING COPY s--� <br />