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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM ALm <br /> SITE cl FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : <br /> COMPLETE THIS FORM FOR EAC11 10 <br /> H AGILITY/SITE `+<„o;d�P <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 HTLV CLOSED SITE F'�' <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / DO <br /> 11 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) v <br /> fV <br /> FAI2nTE NAME <br /> C <br /> �` A ^S� EOF DD <br /> .D CARRESS INFORMATION <br /> ADDRESS (V� {/- /vW NEAREST Ci STREET ✓B011riicek ❑ PARTNERSHIP ❑ CATEAGENCY <br /> Z p l-� r G� �• ❑fA.WOAA➢ON LOCAL AGENCY <br /> ❑ FEDERALAGENCY❑ <br /> CITY N E ✓ STATE ZIP CO '� <br /> CA � BSE PHO E q,WITki!$EA CppE_ <br /> TYPE OF BUSINESS: q p TRIBUTOR 4 PROCESSOR -/Box if INDIAN EPA ID # <br /> 1 GASSTATION 3 FARM 0 5 OTHER RESERVATION or ❑ - #DI TANK', <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS:-yIA^ME(ALA$T,FIRg7 PHONE N/YWWJITH AREA CODE DAV: ME(LAST,FIRST( <br /> SS�/ Q/�Q O) S XA PyOWE q WITH AREA CODE <br /> NIGHTS: Nis i A E(LAST FIRST PHOIJ� WITH AREA CODE NIGHTS rPAME(LAST,FIRST) JJ(PHp�/NElID q WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE OMPLETED) J(//M�_ <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I/Box to indicate ❑ PARTNERSHIP El STATEAGENCY❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE it,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING orS REET ADDRESS ✓Box to indicate ❑ PARTNERSHIP <br /> ❑ CORPORATION ❑ LOCAL- ❑ STATE-AGENCY <br /> CI NAME <br /> ❑ <br /> IN ❑ COUNTY AGENCY.❑ FEDERAL-AGENCY <br /> STATE ZIP CODE TH 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. If. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCYT! FACILITY ID# <br /> IF ofOTANKS DSt SITE <br /> CURRENT LOCAL AGENCY F CILITY ID# APPROVED BY NAME <br /> S �� /� PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PE IT E PIRATION DATE <br /> LOCAT ON CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> ' DATE Ai <br /> 2� . 2-Zi YES E] NO / Z <br /> CME M PERMIT AMOUNT SURCH RGE AMOUNT FEE COOS RECEIPTM <br /> BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO R M B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) 0 . <br /> DATA PROCESSING COPY <br />