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STATE OF CALIFORN* WATER RESOURCES CONTROL BOARD <br /> FORM A : UNDERGROUND STORAGE TANK PROGRAMe <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> rn C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ON i NEW PERMIT ❑.3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE 11 ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0 Z <br /> I.FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) I <br /> FACILITTY/SITE NAME REO ADDRESS INFORMATION <br /> ADORES D AREST CROSS STREET 9nSTATE <br /> 11 �roMGN 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> ❑ iNomou ❑ wuNry-AGENCY 1 �J <br /> CITY NAME STATE P CODE F HONE p,WITH AREA CODE W <br /> CA a <br /> TYPE OF BUSINES : ❑2 DISTRIBUTOR ❑ d P50CESMR Box If ID # / <br /> ❑ I GAS STATION ❑3 FARM ER RESERVATION or /3 l Mof HIS SITANK'TE <br /> 3 <br /> TRUST LANDS ❑ I�Q/V?+ AT THIS SITE J <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> D YS: NAME(LAST,FIRST) PHONE#WITH AREA CODE PAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> �< CYE a��i 99-at3J G'A4�¢ En/ a 3/ <br /> ,FfIGHTS NAME(LAST,FIRST) NEM WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONIFN WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME E OF ADDRESS INFORMATION <br /> % 3 S <br /> -MAlfING or STREET ADDRESS ✓Box to indicift 0 PARTNERSHIP ❑ STATE-AGENCY. <br /> 3AA] CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> / ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> n �y.�� CARE OF ADDRESS <br /> C <br /> AILING a,STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> �/ ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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: 1. 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 /> LO_QAL AGENCY USE ONLY / <br /> 3J OUNTY It JURISDICTION R AGENCY# jj S FACILITY ID R E' of TANKS a1 SITE <br /> o <br /> C RT LOCAL AGENCY FACILITY ID# APPROVED E PH E#WRH AREA CODE <br /> .SEA3 ao�v3J 7 <br /> MIT NUMBERP T APPROVAL DATE PERMIT EXPIRATION DAtE <br /> EEIK <br /> TION C-DDE y 1LS TRACT SU VISOR-DIBTBICT CODE/ BUSINESS LPLAN FILED NO ❑ DA FILED /C` <br /> Or :'lG ERMIT AMOUNT CHARGE AMOUNT/[1 FEE CODE RECEIPT# <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) <br /> 'ssaV. DATA PROCESSING COPY ti.- <br />