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_- <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD F <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM0 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> fA� COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F-1 1 NEW PERMIT F—] 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) <br /> CD <br /> FACILITY/SITE NAME, CARE OF ADDRESS INFORMATION <br /> W ty � <br /> ADDRESS NEAREST CROSS STREET V Box to indicate El PARTNERSHIP 0 STATE-AGENCY <br /> �SWr <br /> J,4X"� -AGENCY El FEDERAL-AGENCY <br /> E,?ORATION ❑ LOCAL <br /> _3 too 0 VIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA 5a3 C0 <br /> TYPE OF BU (NESS: [::] 2 DISTRIBUTOR ❑ 4 PROCESSOR V Box it INDIAN EPA ID 4 #of TANK's <br /> 1-1 RESERVATION or <br /> ❑ 1 GAS STATION �3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> rw, C, 6�� CDo q) 1?97-338 ) I <br /> NIGHTS: NAME(L!AST.FIRST) PHONE#WITH AREA CODE NIGHTS NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS %/Box to indicate 1:1 PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION 1:1 LOCAL-AGENCY El FEDERAL-AGENCY <br /> El INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE I ZIP CODE WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS V Box to indicate El PARTNERSHIP El STATE-AGENCY <br /> El CORPORATION E] LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> El INDIVIDUAL El 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. if. D Ill <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> IAPPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 5771 1 1 El El I I L0101rilol <br /> CURRENT LOCAL AGENCY FACILITY ID APPROVED BY NAME 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 FjLED <br /> YES NO <br /> qq —JiWi�3 C/C� p^[C�• Iff <br /> CHECK A PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> I; a <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIl FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />