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E�Oi�1 <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD . <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAMo <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> /D 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 /> 10 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> le r Se n c 4 ry <br /> ADDRESS NEAREST CROSS STREET ✓Bw I�iMKak ❑ P��W4TNEABNIP D STATE-AGENCY <br /> g, C a '1 r N I r ❑ CDAM7MTION [�EOCAL AGENIX ❑ FEGRNPAGENC <br /> Y 00 <br /> '1 s Ucto µml t0a ❑ INDIVICUAL ❑ COUNT AGENCY 'GVV73`Z7//' <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> SI-0 G X'4-6 v CA a ct K• <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ or <br /> 4 P ESSOP ✓Box if INDIATIONAN EPA ID p #of TANK'# <br /> ❑ 1 GAB STATION ❑ 3 FARM 5 OTHEfl TRUSTMLANDS ATION or ❑ / '/ AT THIS SITE " <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA <br /> RECODE <br /> bac n a - "1l <br /> NIGHTS. NAME(LAST,FI T) PHONE p WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Stl it e r <br /> MAILING or STREET ADDRESS owners ox to indicate D PARTNERSHIP D STATE-AGENCY <br /> CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> S ap a69 `TS - 00 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> (7 <br /> MAILING or STREET ADDRESS n ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D 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 /> a3 = = Do o I a © D <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> / <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED D�A]TE FILED f� <br /> o � 31 FlO O YES NO E] 6/01 Cl <br /> CHECK PERMIT AMOUNT SURCH RGEAMOUNT FEE CODE RECEIPTM BY <br /> T1415 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) <br /> DATA PROCESSING COPY <br />