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�I <br /> STATE OF CALIFORN WATER RESOURCES CONTR BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM - 1 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT <br /> ❑ ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE , <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) a <br /> FACILITY/SITE NAME ^ ' CARE OF ADDRESS INFORMATION <br /> IV <br /> ADDRESS NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> I� ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> IR.0 <br /> CITY NAME STATE ZIP CODE SITE PH NE 4,WITH AREA CODE <br /> Lob CA QS2 333-moi <br /> TYPEBUSINESS F-] 2 DISTRIBUTOR F-14 PROCESSOR ✓Box if INDIAN EPA ID 4 <br /> RESEI GAS STATION El FARM ❑ 5 OTHER TRUSTVANIDS ON or ❑ AT HIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST.FIRST) PHONE 4 WITH AREA CODE DAYS. NAME(LAST,FIRST PHONE 4 WITH AREA CODE <br /> NIGHTS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to incicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /�I n r n ❑ CORPORATION 13LOCAL-AGENCY 1:1 FEDERAL-AGENCY <br /> ��. —I Lc V' ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE I ZIP CODE PHONE 4,WITH AREA CODE <br /> 2 C Z_ <br /> III. TANK OWNER INFORMATION & 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 ❑ FEDERAL-AGENCY <br /> 525 ITT <br /> ElINDIVIDUAL LlCOUNTY-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. ❑ 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 /> 3El I I LLl ) lq <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE k WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE2FIL D <br /> �_z 2_3 , <br /> 7 , (on �Z� YES ❑ NO ❑ T�� �U <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 /> y <br /> DATA PROCESSING COPY <br />