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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD z` _. 'e <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM (% <br /> �' <br /> SITE ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `^<„oa,.> <br /> MARK ONLY ❑ 1 NEW PERMIT [_j 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 P RMA/NElNT CLOSED SITE I"+ <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITYISIT7E INFORMATION <br /> lNQF/�O/R,�/MATI/O^/N�&AD�DRE/AS/S— (MUST BE COMPLETED) m <br /> FACILITY/ NAM/`'— — /"✓L��J""�v CARE OFRESS INFORMATION <br /> ADDRESS ' N E ROSS STREET ✓Bw*axale O PARTNERSHIP Cl SUIE�AGEYLY <br /> ❑❑ NOMTIINI ❑ LOCAL MEN(,Y ❑ RDEW AGENCY <br /> CITY NAME UAL ❑ [OUNIYAGMLC <br /> �) STAT ZIPyODE SITE PHONE N,WITH AREA CODE <br /> CA 9Q - 2 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 SSOR ✓Box if INDIAN EPA 10 N <br /> Ej 1 GAS STATION 3 FARM 5 OTHEfl RESERVATION or O A / N of IT <br /> a 0 <br /> TRUST LEANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DE^NAME ItA5T,FIRST PHONE N WITH AREA CODE D N/µtE(I-AST FIRST) P7ONE N WITH AREA CODE <br /> A ✓{J / / <br /> NIGHTS: N LAST,FIR PH/NE#WITH AREA CODE NIGHT$/NAME(LAST,FIRST) rE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADWADRESS— (MUST BE COMPLETED) J(/FAD <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME S CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. [] IL ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION R AGENCY R FACILITY ID N B of TANKS at SITE <br /> Deo 1 b <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAM PHONE N WITH AREA CODE <br /> �0 I- U_ lL7 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA CENSUS TRACT N SUPERVISO -DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> res ❑ NoPERMIT 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 IS A CHANGE OF SITE INFORMATION ONLY./ <br /> FORM A(3-2-88) J <br /> DATA PROCESSING COPY <br /> 4 <br />