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STATE OF CALIFORNIA~ WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> I <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I-+ <br /> ONE ITEM ❑ p INTERIM PERMIT ❑# AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 7 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) J -4 <br /> FACILITY/SITE NAME <br /> n <br /> CARE OF ADDRESS, ESS INFORMATION <br /> ,vh/- We- <br /> NEAREST <br /> NEAREST CROSS STREET ,�✓Bwbvq� ❑ pARTNER%IP ❑ $TpTE.pGEN6Y <br /> .S� / L-I fDBtlrQiIDN ❑ LGCnLnGENO' ❑ RDBNLMFNLY <br /> IPErIINDMDWI ❑ (X)Un MENCY <br /> CITU NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA Saps <br /> TYPE OF BUSINESS p IBUTOfl 4 PROCESSOR ✓ <br /> ' ❑ ❑ Box i1INDIAN EPA ID p <br /> ❑ 1 GAS STATION 3 FARM It of TANK's <br /> ❑ 5 OTHER TRUST LANDS VATION Dr ❑ " AT THIS SITE J <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> -S/,49- Z <br /> NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box m - ate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> NDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bo in0icale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ RPORATION ❑ LOCAL-AGENCY ❑ 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. if. ❑ 111. ❑ <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 R JURISDICTION R AGENCY R FACILITY ID N R of TANKS B7 SITE <br /> q I 1 14 F/uv © o 16 1 f <br /> CURRENT LOCAL AGEVCY FACILI ID N APPROVED BY NAME PHONE Al WITH AREA CODE <br /> c1414 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK# <br /> DE CENSUS TgACT♦ SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> tMRNITAMOUNT2 3 3 3 2 a YES ❑ No ❑ X0' / i__(" <br /> 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 /> FORMA(32-f18) <br /> DATA PROCESSING COPY <br />