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7 Haws r. -.� .,. • ,.�, <br /> r / <br /> STATE OF CALIFORNk WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM m <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 PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE .7y <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W <br /> FACILIN/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRES"S� ` NEARE TCROSSSTREET ✓BmjW�411PARTNERSHIP ❑ 9ATEAGENGYQ3S i ❑ COENCY 0 FEDERAL-AGENCY <br /> ❑ INGENGYCITY NAME STATE ZIP CODE ITH AREA CODE <br /> CAPE OF SINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID #1 GAS STATION ❑ 3 FARM ❑ S OTHER TRUST LANDS VATION G ❑ AMPIIS SITE <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 /> NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> ; Go <br /> MAILIN rSTREET ADDRESS ✓Boz twMic#le 0 PARTNERSHIP IllSTATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> O • 300 —A 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAMESTATE ZIP DE PHONE#,WITH AREA CODE <br /> S �C c S _- c Ao p V6 -36 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY ❑ 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: I. ❑ 11. 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 If If of TANKS Bt SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMITN MBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENB•��US T2RACTk SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED /� <br /> ® I Q 3 A 0 r� YES NO l �wv <br /> CHECK If PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO RM B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLYP <br /> '\ FORM A(3-2-08) <br /> DATA PROCESSING COPY <br />