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$FATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAMW " <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> n5' �' <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE FORA`' <br /> MARK ONLY 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION, E] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 1:12 INTERIM PERMIT 1:14 AMENDED PERMIT ❑6 TE(APORARY SITE CLOSURE z <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) `� to <br /> FACILITY/SITE NAME ` CARE OF ADDRESS INFOR TION <br /> 00 <br /> ADDRESS NEAREST CROSS STREET ✓Box to Wale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �yG� �• �� I G Y ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENC! <br /> (� GLfROMDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE Of USINESS: ❑2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID# <br /> I GAS STATION ❑3 FARM ❑ 5 OTHER TRUSTRESERVLANDS ATION or ❑ fAT 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 F RS PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> _ 41� <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ALL SEL d <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Po ✓CJ (� ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Z�P/�!�t�;,: <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION 11LOCAL-AGENCY .43 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY / <br /> CITY NAME `STATE ZIP CODE PHONE#,WITH AREA CODE <br /> f <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: L ❑ If. III.❑ <br /> THIS FORM HAS BEEN COMPLETE()UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLI�CA S NA PRIN &SIGNATU E /1 /� `L:l DATE <br /> LOCAL AGENCY USE 6NLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE <br /> 1 <br /> l lklcJ_=� E1 _ 1 I I 1 �) <br /> CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> r .✓ <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> ID,( YES D NO <br /> CHECK A PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 0 BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO RM `B'APPLICATION(Sh UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> `LOCAL AGENCY COPY `�+�' <br />