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STATE OF CALIFORNIA 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 ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 195 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF DORESS INFORMA71 <br /> N e r/�/SP <br /> ADDRE:Sfffe 52d* NEAREST CROSS REET ✓13MIO IoIl, 0 PARI R%W 0 STATEAGENLY <br /> 233 O'T/L fftwl .l 0 COAPOAATDII 0 IOCAAGDO 0 fE➢EPAt.AGB10' <br /> Ne 0 INDMIJUAL 0 COUNW AGENCY <br /> CITY NAME I <br /> STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> Z1,,vWvlA.0 CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOfl ✓BOx if INDIAN EPA ID Al <br /> ❑ I GAS STATION If of TANK's <br /> ❑ 3 FARM ❑ 5 OTHER TRUGTLANDS ION dr ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> AAW50%, p - S" <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 to indicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> /y p 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> .`'• BOA 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE N,WITH AREA CODE <br /> ti � 91.z3e <br /> 111. TANK 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 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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 ADI REBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. v 11. ❑ III. ❑71 <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 N JURISDICTION R AGENCY N 4 �J R of TANKS at SITE <br /> l L <br /> Iz!!T <br /> LOCALADEN FACILITYIDN <br /> 1` APPROVED BY NAME PHONE N WITH AREA CODE <br /> 4V <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> [C]LE <br /> E CENSUS TRACT• SUPERVISOR-DISTRICT CODE BUSINESS KAN FILED DATE f D <br /> 23x� YES NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN 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 ONLX( "V <br /> 1 FORM A(3-2-8!1 <br /> �) \ oN <br />