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STATE OF CALIFORNI91 WATER RESOURCES CONTROL BOARD <br /> W: A <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> Sni_ <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ® , � 1 0 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> CP <br /> MARK ONLY ❑ f NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE FA <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> N <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) CTI <br /> FACILITY/SITE NAME I CARE OF ADDRESS INFORMATION <br /> ADDRESS NEARE T CROSS STREET TO <br /> Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ` Rot CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CY` INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE Zig CODE SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 D RIBUTOR ❑ 4 PROCESSOR */Box if INDIAN EPA ID # <br /> ❑ of TANK's 0C <br /> 1 GAS STATION FARM ❑ 5 OTHER TRUSRTVLANDS 0f ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Lo-7 4 <br /> NIGHTS: NA (LAST,FIRST) OF PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME ! e CARE OF ADDRESS INFORMATION <br /> S&410 <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#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME ,/ CARE OF ADDRESS INFORMATION <br /> .SCPrb�..Q� CCS .�i�I-+� <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#,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. II. ❑ 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# #of TANKS at SITE <br /> [1�1 I I U b-, 10T�T / Ica lyl 16 <br /> -1 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> G <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED 7�veq <br /> � O� � YES ❑ NO ❑CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <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-I) <br /> �, f v DATA PROCESSING COPY <br /> - _ 1 <br />