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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM `. <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 PERMIT ❑S CHANGE OF INFORMATION ❑T PERMANE 0 SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT- ❑4 AMENDED PERMIT ❑S TEMPORARY SITE CLOSURE 7 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> /L ; /a!% S'e, 1—�r—v r S <br /> ADDRESS NEAREST CROSS STREET ✓9ubttiL+1 ❑ wififtW ❑ DA1EAUKLY' <br /> L) -S 0 �recl e,-, �ll. AZ o.f °o oCWMTEN ° `mal MAWO ❑ RlE1W AGEIILY <br /> CI FY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS ❑ p OISTNNITOR ❑/PROCESSOR ✓Boz it INDIAN EPA ID N <br /> RESERVATION of of TANK'N _ <br /> ❑ I GASSIAliON n 7 FARM ❑ SOTHER TRUST LANDS ❑ AT THIS SITE !J <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(UST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE Y WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION III ADDRESS—(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓SON to iM Ie PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box W lnOieele 0 PARTNERSHIP ❑ STATE AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY ❑ 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)BOA INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ IL ❑ NL❑ <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 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY K JURISDICTION Y AGENCY 11 FACILITY ID S I of TANKS AI BITE <br /> CURRENT LOCAL AGENCY FACILITY ID 1 APPROVED EY NAYS PHONE 1 WITH AREA CODE <br /> /urc0La3 <br /> PERMIT NUYEER PERMIT APMOVAL DATE PERMIT EXPIRATION DATE <br /> LOCATLON CODE CENWiTRAGTe tIMlRVIWR-0M1111CT CODE iUNNESE PAN FILED DATENLED --- <br /> lJ 2. > yU 3 �.�• YES NO C/ t <br /> CHECK 1 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEI►T a EY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR NORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF ERE INFORMATION ONLY. <br /> �roHM A Is-z eal <br />