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..;..�.. -. ......,..: . .. ,..._-.ori,--•-•L�. m-;,..,,-rr--.r,-�....,.� _----+'"'r---� �.-,�,...{,;,^s--..,�, .. <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> WP: �Sa <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM , <br /> 0 <br /> SITE V FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FA 1LITY/SITE Cyl Fp RN\P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) w <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Box to indicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ,2ol.6 6) S- C%,��/G r»S ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE a,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑ 2 TRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> If of TANK's <br /> RESERVATION or <br /> ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS 1:1AT THIS SITE uL C <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 /> , o7-5�-/2. c c <br /> lulol <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> C?yrs <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box t 4ndicate 11 PARTNERSHIP ElSTATE-AGENCY <br /> LJ fiHRPORATION 13LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box} indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> U x PORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,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 /> LjL � <br /> CU ENT LOCAL AGENCY FACILITY ID# APPROVED BrITMINEr PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 0 �� 3 2 4, YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT TEE CODE RECEIPT# BY: <br /> r zjl� <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 /> 3 _ q 0 DATA PROCESSING COPY <br />