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•STATE OF CALIFORNIA WATER RESOURCES C*0`14TROL BOARD r� ' <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> " SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> c'�NfoaM�� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> a.r MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMAN TLY LO 0 SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑,AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> FACS /S NAME�� (•' CARE OF SS INFORMATION <br /> AL <br /> ADDRESS X /1 / NFJI ST CROSS STREETW: : <br /> O Bad g LSA Y ❑ SIAIEAGEN�Y <br /> ...r V , �L•'r//Y/'_ ❑ N71N k L❑J COUOY-AOFNGY <br /> IVA <br /> STATE ZIP ODE SITE PHO E WITH AREA CODE <br /> CITY NAME D �. CA ~ 2 <br /> ... TYPE7GAS <br /> NESS: ❑2DISTRIBUTOR ❑4PROCESSOR ✓BoxdINDIAN EPA 10 Ntl of TANKrt ' <br /> ATION ❑3 FARM <br /> ❑5 OTHER TRUSTVLANDS« ❑ N Q AT THIS SITE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> ( p /WITH AREA CODE <br /> DAYS: E(UST,Fl PHONE k WITH AREA CODEr <br /> S;N E(LAST,FlRST)333 <br /> T/ilNE I►WITHAREACODE <br /> NIGHTS: NAME( FIRST) PHO E 0 WITH AREA CODEHTS: AME(LAST.FIRST) <br /> 4 31A <br /> II. PROPERTY OWNER INFORMATION dl ADDRESS— (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> i.r ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MAIL&or STREET ADDRESS ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY•AOENCY <br /> STATE ZIP CODE PHONE 11,WITH AREA CODE <br /> CITY NAME <br /> wr <br /> Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> x,_ <br /> ..r NO or STREET ADDRESS -/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MA <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> S..i <br /> CITY NAME STATE ZIP CODE PHONE R,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> ti CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDREU SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND 81LLING: I. It. ❑ 111•❑ <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 8 SIGNATURE) GATE <br /> S.r <br /> LOCAL AGENCY USE ONLY <br /> v COUNTY S JURISDICTION S AGENCY S FACILITY 10 M S of TANKS at SITE <br /> 1311 Fpo Do 0 <br /> PHONE It WITH AREA COOK <br /> C RRENT�CAOENGY fACILITY ID• App OVED SY NAM Z <br /> EE 33 PERMIT APPROVAL DATE <br /> PERMIT RATION DATE <br /> PERMIT NUMBER <br /> sr <br /> ATE FILED <br /> LOC ON CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE 6USINESS PLAN FILED q <br /> Z oQ YES NO to 1 <br /> ..r CHECK• <br /> PERMIT AMOUNT SURCHARGE AMOUNT FE!CODE RECEIPT 1 SY: <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(3-2-115) r <br /> �..,/ DATA PROCESSING COPY L <br />