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ti <br /> STATE OF CALIFORN19 WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM no <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE )"a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Jr 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST, BE COMPLETED) w <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> n I I I-e,(:s V C' u t4j_ <br /> ADDRESS NEAREST CROSS STREET ✓Box to indole ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> " (t`1 W a_-LvL LCu f , El CORPORATION 11 LOCAL-AGENCY El FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY ar LL A� <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> Sf kms►--, CA QS 3 0<�_ - <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID# <br /> RESERVATION or #of TANK', <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑'"THER 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) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS—(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 01 CILr I LL'_)-0- <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Q �1 ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ' Pjp�c all ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CO- Gy�Is <br /> III. TANK OWNER INFO ATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl 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 USE 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 /> r\ I v::) <br /> LOCAL AGENCY USE ONLY <br /> FCHECK# <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> t yLO :AGENCY FACILITY ID# PPROVED BYNAME PHONE#WITH AREA CODE <br /> l.p <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILEDp /�L4 YES ❑ NO ❑ )a C � Cl c PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <br /> Y. <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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY ✓\J <br />