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STATE OF CALIFORA WATER RESOURCES CONT• BOARD <br />FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br />SITE_ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br />ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 50 <br />I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />FACILITY/SITE NAME <br />CARE OF ADDRESS INFO RMATI N <br />e-yj H%h C <br />Licitr A -P Sy <br />ADDRESS <br />,. I� <br />S�l-,[_ s� <br />NEAREST CROSS STREE <br />NEAREST <br />S��L <br />✓Baai#'XAa D PAWNERSHP D STATE AGECY <br />g CDWMTIGN El LOX-AGENLY El FEDERAL. <br />V'S <br />1 <br />0 INDMOUAL 0 OXAM AGENCY <br />CITY NA <br />i <br />STATE <br />ZIP CODE SITE PHONE 11, WITH AREA CODE <br />i Pon <br />CA <br />2-05 5 9 <br />TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 44 PPRRO,iCrESSSOR <br />✓Bac if INDIAN <br />EPA IC a <br />PERMIT AMOUNT <br />I❑ <br />i GAB STATION 3 FARM <br />❑ ❑ <br />ATION <br />❑ <br />FEE CODE <br />A' of TANK' <br />Lida"'"�" <br />TRUSTLANDSDT <br />AT THIS SITE <br />ISSIS <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYS: NAME (LAST, FIRST) PHONE k WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) PHONE N WITH AREA CODE <br />C4L&-ee4->S4- a09sq (p (tio <br />NIGHTS: NAME (LAST, FIRST) PHONE a WITH AREA CODE <br />—' <br />NIGHTSNAME (LAST, FIRST) PHONE N WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLFTFDI <br />NAME <br />11 a -v"'.0 — <br />CARE OF ADDRESS INFORMATION <br />LQ.v v l Gy-eC4__l <br />5,V_ <br />MAILINGor REETADDRE S J <br />✓BOX to Indicate <br />D CORPORATION <br />0 INDIVIDUAL <br />D PARTNERSHIP 0 STATE -AGENCY <br />D LOCAL -AGENCY 0 FEDERAL -AGENCY <br />0 COUNTY -AGENCY L7 <br />CITY NAME^ I o <br />STATS <br />21Pl,� <br />3,, � <br />PHONE <br />00(S AREA CODE I <br />Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETEDI <br />NAMEnn <br />CARE OF ADDRESS INFORMATION <br />� <br />az <br />FACILITY ID # M of TANKS at SITE <br />I al O o 1 a I J 0 1 o I—C)l <br />MAILING or STREET ADDRESS <br />I/ Box to indicate 0 PARTNERSHIP 0 STATE -AGENCY <br />APPROVED BY NAME PHONE M WITH AREA CODE <br />0 CORPORATION D LOCAL -AGENCY D FEDERAL -AGENCY <br />D INDIVIDUAL 0 COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE PHONE N, 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. ❑ if. Q Ill. ❑ <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 # <br />Eu <br />JURISDICTION At <br />= <br />AGENCY # <br />= <br />FACILITY ID # M of TANKS at SITE <br />I al O o 1 a I J 0 1 o I—C)l <br />CURRENT LOCAL AGENCY FACILITY ID N <br />1 <br />.5 <br />APPROVED BY NAME PHONE M WITH AREA CODE <br />PERMIT NUMBER <br />PERMIT APPROVAL DATE <br />PERMIT EXPIRATION DATE <br />LLOCATIONCODEOD <br />CENSUSTRACT# \ <br />OlJ <br />SUPERVISOR -DISTRICT CODE <br />BUSINESS PLAN FILED <br />YESE] NO <br />DA EFILED <br />PERMIT AMOUNT <br />SURCHARGE AMOUNT <br />FEE CODE <br />RECEIPT# <br />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 ONL . <br />` FORM A (3 -2 -DS) • <br />V 0 <br />DATA PROCESSING COPY <br />