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STATE OF CALIFORNIX WATER RESOURCES CONTROl'BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V " <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' : C) <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I'+ <br /> ONE ITEM ❑ 3 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) (in <br /> W <br /> FACILITY/SITE AME CARE OF ADDRESS INFORMATION <br /> ADDRE p6+� / L L n NEAREST CROSS STREET ✓Bmb rd,210 ❑ PARtryEgSNp ❑ yT u AGENCY <br /> 7 /O (/LX'f�'/7fN� /'�!/� ❑ COWORATlaR ❑ Loca AGDO ❑ FEDERAL AGENCY <br /> �J ❑ INGMDIAI ❑ WUNWAGENC1 <br /> CITY NA�/ r�I/✓" STATE ZIP CODE SITE PHONE A,WITH AREA CODE <br /> .`l CA 2L2S— <br /> TYPE OF BUSINESS ❑ y RIBUTOR ❑ <PROCESSOR ✓Boz tl INDIAN EPA ID R <br /> ❑ I GAS STATION V3FARM ❑ 5 OTHER RESERVATION or ❑ N of TANK'S <br /> LANDSAT 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 /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME p ` CARE OF ADDRESS INFORMATION <br /> L as <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ 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: L 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 R JURISDICTION N AGENCY R FACILITY ID M I-IZ y R of TANKS at SITE <br /> m 1;2- 1-//( oa <br /> CURRENT LOCAL AGENCY FACILITYID APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBE RMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> FLOCATIONE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILE(574f72325 3 �-S- YES ❑ NG ❑ 4 1 <br /> PERMIT AMOUNT SURCHARGE AMOUNT 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 ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />