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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> SITE UNDERGROUND STORAGE TANK PROGRAM u " <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONZ <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �q Ford e 1 0 <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ONE ITEM ❑ / P LY CLOSED SITE FJ <br /> 2 INTERIM PERMIT �q AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME /� <br /> �✓\ CARE OF ADDRESS INFORMATION vI <br /> A <br /> ADDRESS <br /> NEAREST CROSS STREET ✓) iMicate ❑ PARTNERSHIP El STATE AGENCY <br /> OC 1-'( (�f / /•`/p_/La L>CAAPORATION ❑ LOX AGENCY ❑ FEDERAL AGENCY <br /> CITY NAME ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> STATE ZIP ODE SITE PHONE 4,WITH AREA CODE <br /> TYPE OF BUSINESS: 2 DISTRIIBBUUTTOORRIL❑ f PROCESSOR ✓Box if INDIAN EPA D ttA �D r <br /> 1 GAS STATION ❑ 3 FARM �OTryER RESERVATION or ❑ ��, #of TANK's <br /> TRUST LANDS 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( <br /> �O SE yV /A 0q (06_ PHONE p WITH AREA CODE <br /> NIGHTS: AME(LAST,FIRST) (I I PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> 's G(/)1�� PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAPNAME , ^ <br /> _•}1-,/a - K CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS <br /> t11 ✓ xto intlicale ❑ PARTNERSHIP Cl STATEAGENCY1 CORPORATION ❑ LOCALAGENCY ❑ FEDERAL AGENCY <br /> CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> 9 �J STATE ZIP CODE PHONE#,W TH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) S g 6 35(0 <br /> [NAME (� E- . - <br /> IV. <br /> INFORMATION <br /> AILING or STREET gpDRESS e ❑ PARTNERSHIPON ❑ LOCAL-AGENCY STATE-AGENCY <br /> TU NAME ❑ COUNTY- El FEDERAL-AGENCY <br /> AGENCYH AREA CODE <br /> 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 MV KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCYAF FACILITY ID N <br /> 3 � �m of TANKS at SITE <br /> CURRENT LO AL AGENCY FACILITY ID# <br /> Ca APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER d PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> YES o NO DATE FILED ZJ� <br /> FVC <br /> CMECKIII PERMIT AMOUNT SURCHARGE AMOUNT <br /> FEE CODE gECE1PTM SY <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 /> 0 DATA PROCESSING COPY <br />