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71 <br /> " STATE OF CALIFORNIA WATER RESOURCES CONTROL BOAR® <br /> FORM `A': UN®ERGROUND STORAGE TANK PROGRAM W <br /> Y 1 "®. to <br /> , <br /> glTIE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C'atIFORN\�` <br /> COMPLETE THIS FARM.FOR EACH F ILITY/SITE <br /> MARK ONLY I NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE <br /> s <br /> — ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE �. ) <br /> 1. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Box to iodate ❑ PARTNERSHIP ❑ STATE-AGENCY �+ <br /> RATION ❑ LOCAL-AGENCY FEDERAL-AGENCY op <br /> ❑ <br /> IND ❑..DUAL ❑ COUNTY-AGENCY <br /> STATE ZIP <br /> PTEPH NE a,WITH AREA CODE <br /> CITY NAME <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID a A of TANK's <br /> STATION ❑3 FARM <br /> ❑5 OTHER TRUSTVLAAT DN or AT THIS SITE <br /> ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> DAYS' NAME(LAST,FIRST) /��,f <br /> NIGHTS: NAME(LAST.FFIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE a WITH AREA CODE <br /> rJ U l <br /> II. PROPERTY OWNER INFORMATION &ADDRESS-(MUST BE COMPLETED) \ <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> �s L G� <br /> or STREET ADDRESS �✓Bogc to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MAILI <br /> L-i-OORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> a/ STATE ZIP CODE PHONE a,WITH AREA CODE <br /> CITY NAME 62 <br /> ♦ r <br /> 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) C>�� <br /> NAME CARE OF ADDRESS INFORMATlONI J <br /> SS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRE <br /> ❑ CORPORATION ❑ LOCAL-AGENCY [:1 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE a,WITH AREA CODE <br /> CITY NAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOlf BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II. �IIL❑ <br /> S-.. <br /> THIS FORM HAS BEEN CO POET£ UNDER P NALTY QE PE JURV,•A"ND TO THE,9ESITL0 11�M1'�KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICAN ' NA (PRINT &ISIGNATURE ;� �-' /J, �l/7 DATE <br /> LOCAL AGENCY USE,O Y <br /> COUNTY E JURISDICTION If AGENCY If',.: <br /> FACILITY IDA A of TANKS at SITE <br /> El= <br /> ❑ <br /> CURRENT LOCAL AG \; <br /> PHONE A WITH AREA CODE <br /> ENCY FACILITY IDA APPROVED BY NAME <br /> , <br /> PERMIT NUMBER APPROVAL DATE PERMIT EXPIRATION DATE <br /> (.. '- PERMIT AP \C <br /> q LOCATION CODE" CENSUS TRACT A SUPERVISQR.DISICY`CODE BUSINESS PLAN FILED <br /> DATE FIL D <br /> ` Q, /I'a YES C] NO <br /> ❑ <br /> CHECK A PERMIT AMOUNT <br /> SURCHARGE AMOUNT FEE CODE RECEIPT A BY: <br /> THIS FORM MUST BE ACCOMPANIED BY ST(1)OR MORE TANK PERMIT FORM 'B'APPLICATI S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) ' <br /> DATA PROCESSING COPY <br />