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STATE OF CALIFORNIA' WATER RESOURCES CONTROL BOARD <br /> FORM ' <br /> A,: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE /L FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> �I COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION [:,:] I PERMANENTLY CLOSED SITE 1"A, <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE v <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) -4 <br /> CD <br /> FACILITY/SITE NAMECARECARE OF ADDRESS INFORMATION <br /> Kodne N Arl <br /> ADDRESS c NEAREST CROSS STREET ✓Bax Cl PARTNERSHIP ❑ STATEAGENCY <br /> 6 DO N, %J L I('�F / DN 0 LOCk AGENCY 0 P3lEML AGENCY <br /> INorvlouN ❑ courmAGExcY <br /> CITY NAME STATE ZIP CODE SITE PHONE M.WITH AREA CODE <br /> Gf/ CA SZyU <br /> TYPE OF BUSINESS: ❑ 2 p IBUTOR F—] 4 PROCESSOR ✓Box it INDIAN EPA ID N <br /> RESERVATION or Mol TA74K'L <br /> ❑ 1 GASSTATION 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS ME(LAST,F RST) PHONE x WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LA RST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY ❑ 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 / CARE OF ADDRESS INFORMATION <br /> A'1 <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY Cl 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: 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION M AGENCY M FACILITY ID M M o/TANKS at SITE <br /> CURRENT LOOLL GEN Y FACILITY I APPROVED 8Y NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCAT(ID�J4 CODE CENSUS TRACT M SUPERVI80 -DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> ! Z Z YES El NO ❑ 3—if <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 />