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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V ... yl�" <br /> SITE j FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -� Z <br /> �- COMPLETE THIS FORM FOR EACH FACILITY/SITE `+�r.oae�" 10 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY SITE CLOSURE 5'0 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ou ar s <br /> ADDRESS NEAREST CROSS STREET ✓ftovdceR 0 FAATNEFMIP ❑ STATE AGENCY <br /> I NCs� 0 MV MTDN 0 LOCAL-AGENCY 0 FEDBNLAGE10 <br /> 0 INDNIGUV. 0 OWMAGENC( <br /> CITY NAMESTATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA S336 <br /> TYPE OF BUSINESS'. ❑p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box IT INDIAN EPA ID a <br /> ❑ I GAS STATION ❑ 3 FARM ❑5 OTHER RESERVATION or ❑ M of TANK'N <br /> TRUSTLANDSAT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE k 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 & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE DECODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 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 It.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: L ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION k AGENCY N FACILITY ID M N o1 TANKS at SITE <br /> yo s <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE SUS N BUPERVIBOR CODE BUSINESS PUNFILEDDATE FILED <br /> ' 5'— FNO ❑ q/ <br /> 3 3 <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT p BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAF"1)OR MORE TANK PERMIT FORM 'B'APPLICATIONIS), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. \ <br />\ /FORMA(3-2-138) <br /> V • S�r-� l — � DATA PROCESSING COPY V �./ <br />