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STATE OF CALIFORNIN WATER RESOURCES CONTROBOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> S� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> G COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE On <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) � <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> GU `Str;C <br /> ADDRESS o NEAREST CROSS STREET wdom 0 PARINBENIP 0 SrATEAGENCY <br /> RPORATION W -AGENCY 1:1 FEDERAL AGENCY <br /> Q W/' ❑ INOIYIWAL NIY-AGENCY <br /> CITY NAME STATE ZIP CODE SIT PHONE tkITH AREA CODE <br /> CA ab <br /> TYPE OF BUSINES : ❑ 2 DISTRIBUTOR ❑4 P SWR ✓Box it INDIAN EPA ID a <br /> 11 RESERVATION or Mol TANKa <br /> ❑ I GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ / �� P`-"`-� AT THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S Cao "Nf-0537 <br /> NIGHTS: NAME(LAST.FIRST)� p PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME 0 %CARE OF ADDRESS INFORMATION <br /> 6l D"S <br /> MAILIN STREETADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> C CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> D INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME E ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> a er <br /> MAILING or STREET ADDRESSV Box to indicate Cl PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CCDE PHONE It,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. 11V 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEDG IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION M AGENCY M FACILITY ID M M of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK# <br /> E CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3 YES NO � D <br /> i <br /> PERMIT AMOUNT SURC ARGE AMOUNT FEE CODE RECEIPT M BY: <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 /> DATA PROCESSING COPY J <br />