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. } <br /> STATE OF CALIFORNO WATER RESOURCES CONTRL_ BOARD ISS:"ow."ThE'•� <br /> FORM `A': sA _ <br /> UNDERGROUND STORAGE TANK PROGRAM "gym <br /> _ <br /> Y M 0 ray <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME C OF ADDRESS IN FOR ION <br /> ADDRESS NEAREST CROSS STREET ✓moo irdule ❑ PARTNERSHIP ❑ STATE AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SI E PHONE#,WITH AREA CODE <br /> CA G S Zl 2 Z0�1 q <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or #of TANK's <br /> ❑ t GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ �ATTHISSITE <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 /> C � <br /> NIGHTS: ME(LAST, IRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST, ST) PHONE#WITH AREA CODE <br /> ( ) �► s <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME GQ CARE OF ADDRESS INFORMATION <br /> L <br /> MAILING or STREET ADDRESS ✓BOW16 indicate ElPARTNERSHIP ElSTATE-AGENCY <br /> El LOCAL-AGENCY FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAM STATE ZIP CODE PHONE# WITH AREA CODE <br /> 45 I — -.- 4 14 <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME , 1 CARE OF ADDRESS INFORMATION <br /> N <br /> MAILI or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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. ❑ II. ❑ 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# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 2-al I I I I EI I I I I I 1 ,511 O O <br /> CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED <br /> 3 YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT 7FEE CODE RECEIPT# BY: <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 I FORMATION ONLY. <br /> 1 FORM A(3-2-08) <br /> DATA PROCESSING COPY <br />