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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANE ITE F'a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE -4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) CD <br /> CD <br /> FACILITY/SITE -, �y^ � CAR/`JO;�RESS INFORMATION <br /> ADDRESS S / ` 'A NE STC OSS STREET ✓BGIoiMiwh <br /> l ✓wY�L] 'IJCJ r ❑ AE0 STATE <br /> ` 0 WAIDk=NAGENCY 0 ED AAAGN <br /> fiv <br /> ❑ INOrv10UAl ❑ GOUNttAGENCY <br /> CITY NAME ATEC00 SITE PHO E WITH A A C DE <br /> 2 <br /> CA Z�6 ; <br /> TYPE OF BUSINESS' 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA # _ If of TANK'S <br /> ❑ ❑ ID RESERVATION or /� <br /> ❑ I GAS STATION F__] 3FAF OTHER TRUST LANDS ❑ 601 `67 � AT THIS SITE It <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAV NAME(LASTjD, �� PHONE M WITHARJEA OE DAYS. AME(LAST,FIRST) P p WITH AREA CODE <br /> J/7 ,,ll/�// a <br /> NIGHTS AME(LAST,FIRST) PHONE N WITH AREA CODE NIG U NAME(LAST,FIRST) P p WITH AREA CODE <br /> F <br /> II. PROP RTY OWNER INFORMATION &ADDRESS — (MUST 6E COMPLETED) <br /> NAME C . A, CAR OF ADDRESS INFORMATION <br /> MAILI rSTREET SS \ A , ^ �/ ✓V-BoxCO to indicate 0 P N-AGEN 0 STATE-AGENCY <br /> /CJiw-- ,l 0 CORPORATION LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> Cl INDIVIDUAL 0 COUNTYAGENCY <br /> CITY N l��lr STATE ZIP CODE PHONE$1, ITH R C DE <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILINA or STREET ADDRESS i"Box to indeale 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A.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. =111. ❑ 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 A,SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY B FACILITY ID N M of TANKS B1 SITE <br /> 0 ° 11 1/ r Jo Ij I 1 <br /> CURRENT AL AGENCY FACILITY IDN APPROVE E PHONE k WITH AREA CODE <br /> MIT NUMBER �,��VVfJllllA••'11J PERMIT APPROVAL DATE ERMIMI"T( PIRA ION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISO -DISTRICT BUSINESS PLAN FILED ;DAT7E �ED <br /> arJ�� YES NO <br /> /71 <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> 1 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 /> %R/ DATA PROCESSING COPY `ow <br />