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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 'x` <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 ❑5 CHANGE OF INFORMATION ❑ 7 FERMAN SITE F"+ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓w,b- ' ❑ PAPixEASYP ❑ STATE-AGENCY <br /> S ❑ RATION ❑ LO AGENLY ❑ FEDSIAL AGED <br /> INDMOUAL ❑ WUNTYAGBICI <br /> CITY NAME STATE ZIPCODE SITE PHONE N,WITH AREA CODE <br /> L©ct1 CA sato (( i <br /> TYPEOF BUSINESS'. 0235RWOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID N <br /> RESERVATION or X of TANK'N <br /> ❑ I GAS TION FARM ❑5 OTHER TRUST LANDS ❑ L- 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 /> - <br /> NIGHTS: 14AME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> d1 .-t7 . <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S�•T ry n <br /> MAILING or STREET ADDRESS ✓Box to ine ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CO ATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> lil IVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME c CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS SO <br /> indioo. ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ 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 ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. IL ❑ 111.❑ <br /> I`{ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION R AGENCY N FACILITY ID If N of TANKS at SITE <br /> I I dL d 7 1 1010 101 <br /> CURRENT LOCAL�JNCY F�AACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> v[✓✓✓ 1 1 <br /> PERMIT NUMBER PERMR APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE I CENSUS TRACT SU PERVISOR•DISTRICT CODE BUSINESS PLAN FILEDDATEFILED <br /> d 3 YES NO <br /> lCHECK N PERMIT AMOUNT SURCHARGEAMOUNT FEE CODE RECEIPT N BY: <br /> h I 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 /> �V FORM A(3-2-BB) <br /> DATA PROCESSING COPY <br />