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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM =y �o Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Ic <br /> TCOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ri <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAMECARE OsADDRESS INFORMATION <br /> �� r6rw (� <br /> ADDRESS NEAREST C'OSS STREEi� ino/ ✓ vJonPARINBBNIP 0 STATE-AGENCI <br /> 2 L N (�r(PS G1 icale 0 WOFATIDN ❑ LOCAL AGBIa ElR ERAS AGENO <br /> mouAL ❑ McliFf-AGENCY <br /> CITY NAMESTATE ZjkCODE ITE PH NE#.AITH AREA CODE <br /> /,64 CA y5lro 2 <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID # #of TANK's 00Z <br /> EMERGENCY <br /> ❑ RESE <br /> I GAS STATION [:] 3 FARM 5 <br /> OTHER TRUSTYLANDS or ❑ ll/V AT THIS SITE(f <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS NAME LAST.FIRST) PHONE N WITH AREA CODE <br /> oq36q zf U N <br /> NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> 2 1!h 3 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME j CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING or STREET ADORE ✓ ox to intlicale Cl PARTNERSHIP 0 STATEAGENCY <br /> 0 C/p ♦ RPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> Cl INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME ST E_ ODE PHONE#,WITH AREA CODE <br /> Cc�42 D 2-o 41 <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> slimt; Trd S <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> Cl INDIVIDUAL 0 COUNTYAGENCY <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. ❑ If. 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# JURISDICTION# AGENCY# FACILITY ID If #o1 TANKS at SITE <br /> zit 10101010 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> E <br /> DE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL D <br /> 2YES � NO `, Cy PERMIT AMOUNT SURCHARGEA UNT FEE CODE RECEIPT# BY: <br /> 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 ONL <br /> FORM A(3-2-M) <br /> V DATA PROCESSING COPY Ifti <br />