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STATE OF CALIFORNM WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM " <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Lff3MANENTLY CLOSED SITE 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) to <br /> W <br /> FACILITY/SITE NAMCARE OF ADDRESS INFORMATION <br /> AUL 17 FMA NS6 <br /> ADDRESS ^ NEAREST CROSS STREET bin=TO ❑ ?MTFILDCAL ASAP C FEDERLAGEM <br /> J(/( IX7RgMiIDN ❑ LOCALERSHIP/ ❑ STATE GEN NC( <br /> Cl INDIVIDUAL C COUNtt-AGENCY <br /> CITY NAME GSTATE ZIP CODE <br /> SITE PHONE A,WITH AREA CODE <br /> � <br /> TYPE OF BUSINESS: ❑ DISTRIBUTOR F-] 4 PROCESSOR ✓Box if INDI N EPA ID # <br /> RESERVATION or #of TANK's <br /> [:] 1 GAS STATION 3 FARM El OTHER TRUST LANDS ❑ 1 AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> S: NAME LAST,FIRST) / PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE�#WITH AREA CODE <br /> D /v R LIZ Lle V e <br /> NIGHTS'. NADE(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION III ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate C PARTNERSHIP C STATE-AGENCY <br /> ❑ CORPORATION C LOCAL-AGENCY i C FEDERALAGENCY <br /> C INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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 C PARTNERSHIP ❑ STATE-AGENCY <br /> C CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> ❑ INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.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. it. El <br /> ❑ 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 8 SIGNATURE) DATE <br /> —771 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID IF #of TANKS BI SITE <br /> = MaRl= rOlo 1019- <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT ODE BUSINESSPSN FILED NO ❑ DATE FILED./-7- <br /> YES <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY6 <br /> TMS 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(3-2-819) S <br /> DATA PROCESSING COPY '../ <br />