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STATE OF CALIFORNIA <br /> FORM 'A': WATER RESOURCES CONTRAgRD <br /> SITEUNDERGROUND STORAGE TANK PROGRAM <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION i <br /> COMPLETE THIS FORM FOR EACH F <br /> FMARK ONLY I NEW PERMIT CILITY/SITE ,ia 1® <br /> _RN P <br /> ONE ITEM ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> 2 INTERIM PERMIT E]4 AMENDED PERMIT ❑ PERMANENTLY CLOSED SITE <br /> L FACILITY/SITE INFORMATION & ADDRESS — s TEMPORARrsI7Ec CLOSURE <br /> FACILI E NAME <br /> (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION Q <br /> ADDRESS <br /> CITY NAME NEA REST CROSS STREET <br /> ✓Boa to in0irate ❑ PARTNERSHIP ❑ SiATFAGENCt <br /> ❑ CORPOFATION 0 LOCALAGENCY❑ INONI UAL 0 CGUNYAGRCY 0 FEDERAL AGENCY <br /> STATE ZIP CODE <br /> TYPE OF BUSINESS' (] p nmTRIBUTOR 4 PROCESS ✓ ID SITE PHONE H,WITH AREA CODE <br /> I GAS STATION IL`✓J��9�FA"gM ❑ Box if INDIAN EPA Ip q J .7 <br /> 5 OTHER RESERVATION or ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) TRUST LANDS A THIS SITE <br /> DAYS NAME(LAST,FIRST) <br /> EMERGENCY CONTACT PERSON AT THIS SITE <br /> M�n I .I PHONE#WITH AREA CODE DAYS NAME(LAST,FIRST) AT <br /> NIGHTS: NAME(LgST,FIRST) //�AA/-` PHONE q WITH AREA CODE <br /> PHONE p WITH AREA CODE j NIGHTS: NAME(LAST,FIRST) <br /> II. <br /> PROPERTY OWNER INFORMATION &ADDRESS — PHONEgwIrHAREAcoDE <br /> NAME (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> MAILING o,STREET ADDRESS <br /> ✓Box to ift,,ato 0 PARTNERSHIP <br /> PART <br /> CITY NAME 0 CORPORATION ❑ LOCAL-AGENCY 0 STATE-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY- 0 FEDERAL-AGENCY <br /> STATE AGENCY <br /> ZIP CODE PHONE b,WITH AREA CODE <br /> 111. TANK O ER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING o,STREET ADDRESS <br /> ✓Box to indicate 0 PARTNERSHIP <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> CITY NAME ❑ INDIVIDUAL 0 COUNTY- 0 FEDERAL-AGENCY <br /> STATE AGENCY <br /> ZIP CODE PHONE q,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK 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 8 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> co� JLgI9D/CT/ONX AGENCY# <br /> FACILITY IDA A of;TAANqKSatITEALAG NCJJJffS��FACILITYID# V <br /> /I APPROVED BY NAMEPHONE# ODE <br /> PERMIT NO---M"BBBEIR { PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> LOCAT DE CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> DATE FILED <br /> CHECK# PERMIT AMOUNTYES NO <br /> SURCHARGE AMOUNT <br /> FEE CODE U/ o <br /> RECEIPTM 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 /> 0 DATA PROCESSING COPY <br />