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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD s`� \ <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE n FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION f <br /> - V' COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMAN DSITE N <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE m <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> .B. <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ctv.Svn a1 <br /> ADDRESS NEAREST CROSS STREET ✓Box o,W.QRP ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ INATION 11LocALAGENCY 11FEDERALAGENCY <br /> ,I,G,,L ❑ courvT AGENcY <br /> CITY NAME _ STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> / O/J CA 953 (o/ �C99- q -3oJU/ <br /> TYPE OF BUSINESS ❑ p TRIBUTOR ❑4 PROCESSOR ✓81x it INDIAN EPA ID p <br /> ❑ I GAS STATION 3 FARM ❑ 5OTHER TRURESSTYATION LANDS or ❑ . AT THIS SITE / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) HONE p TH AREA CODE DAYS' NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> �09- Y`!- Sao i <br /> w Sa A P <br /> NIGHTS: NAME(LAST,FIRST) PHONE ft WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE tt WITH AREA CODE <br /> .5'a.•n..Q Scr r.1.¢. <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> A6v v e 7- <br /> MAILINGarSTREET ADDRESS ✓Box indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> NDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE 17 <br /> CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> b o ve Z <br /> MAILING or STREET ADDRESS ✓Box indicate 11 PARTNERSHIP 13 STATE-AGENCY <br /> ❑ RPORATION IllLOCAL-AGENCY 11FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE W,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. ❑ 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# AGENCY41, FACILITYID# #of TANKS at SITE <br /> ALOCAL <br /> g p o v / <br /> CUENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT ERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CYFEE <br /> BUSINESSPUN FILED DATE FILED <br /> 3.2�. 3a(o YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNTODE RECEIPTp BY: �/� <br /> C13 <br /> THIS FORM MUST BE ACCOMPANIE"Y AT LEAST(1&ORE TANK PERMIT FORM 'B'APPLICATION(S), UNL IS A CHANGE OF SITE INFORMATION ONLY. 5 <br /> FORM A I3-2-88�� .p� �J <br /> /� � W DATA PROCESSING COPY <br />