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STATE OF CALIFORNIA-' WATER RESOURCES CONTROt'eOARD <br /> 4e�� rMp <br /> i <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM `" �"" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° o <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE �""=°='" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMITCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I'a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 00 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> <O <br /> FACILITY/SITENAME CARE OFADDRESS INFORMATION <br /> ADDREBSNEA EST CROSS STREET ✓ mom ❑ PP6iNFHSNF ❑ SiA KENCY <br /> eweA ❑ MTION IONDU4 13 COUNIYC3 LAAGENCY OEICY [I �EA.V--AGENCY <br /> CITY NAMES <br /> STATE ZIP ODE TE PHONE a,WITH AREA CODE <br /> - CA U 09 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR r-] 4 PROCESSOR ✓Box if INDIAN EPA ID a aof TAN <br /> ❑ SE <br /> 1 STATION ❑ 3 FARM �THER TRUSTYLANDS or ❑ ' SII <br /> GAS <br /> AT THIS SITE /U <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> WDD l e-1 / <br /> NIGHTS'. NAME(LAST. ST) PH NE aWITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME 4 Y CARE OF ADDRESS INFORMATION <br /> MAILING of STREETA ESS ✓ to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> / ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> G ct4q 5 <br /> III. TANK WNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> e <br /> MA11 G or STREET KESS ✓BOKio intlicate ClPARTNERSHIP ❑ STATE-AGENCY <br /> ['YC'ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ^ ZIP CODE O PHONE a,WITH AREA CODE <br /> 'slo <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS C n[/J <br /> CHECK ONE(1)BOX INDICATING 1NNICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a AGENCY R FACILITY ID R a of TANKS BI SITE <br /> Da <br /> 1 0 O <br /> CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE N WITH AREA CODE <br /> S <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATICHILCODE CENSUS TRACT a SUPERVISOR-DISTRICT LODE BUSINESS PLAN FILED DATE FILED <br /> A <br /> -3 �O a, YES NO 5 <br /> LITE K a PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: <br /> I 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 OHL . <br /> '\1\� FORM A(3-2A8) <br /> DATA PROCESSING COPY www <br />