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STATE OF CALIFORNIA-� WATER RESOURCES CONTRO40ARD A <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> RANGE OF INFORMATION T PER CLOSED SITE - <br /> PERMIT E 3 RENEWAL PERMIT D N <br /> MARK ONLY q AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> ONE ITEM INTERIM PERMIT El <br /> N <br /> 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BEGCOMPDLETED RMA ION <br /> FACILITY/SIT NAME L / <br /> NEAREST CROSS STREET ✓BaAto irxuce 0 LOCAL <br /> LAGEN 0 PENFATAGENCY <br /> I 1 0 CORPORATION 0 LOUNTY AGER ❑ PENAL AGENCY <br /> CY <br /> AODR SS J ' ❑ INONIOlIA1 ❑ COIINLWITH <br /> STATE ZI CODE 5 TE PHON N.WITH AREA CODE <br /> CITU NAME DG /7 CA sa.a� aa9 a <br /> I(r`T ✓Box if INDIAN EPA IID N S of TANK's <br /> TYPE OF BUSINESB'. p DISTRIBUTOR <PR SSOR RESERVATION or ❑ - AT THIS SITE <br /> 1 GAS STATION 0 3 FARM OTRER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(SECONDARY) <br /> EMERGENCY CONTACT PERSON(PRIMARY) <br /> PHONE if WITH AREA CODE <br /> DAYS NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) <br /> Me ;s /" IV. aoq <br /> NIGHTS: NAME(LAST.FIRS I <br /> PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> _Ecl�yr a S Q <br /> MAILING or STREET ADDRESS ✓Box tointlicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION C LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> as S / e <br /> MAILING or STREET ADDRESS ✓Box to Inoicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION C LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE 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.XII. ❑ 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) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N B of TANKS at SITE <br /> CURRENT LOCAL AGENCY F'AKnCILITY IDN APPROV SY NAME PHONE N WITH AREA CODE <br /> l <br /> I 49 <br /> PERMIT NUMBER PERMIT VAL DATE PERMIT EXPIRATIl ,ION DA <br /> ee 9 <br /> LO"TION CENSU TRACT UPERVISOR-DISTRICT CODE BUSINESS N FILE DATE FILED <br /> YES ❑ NOPERMIT AMOUNT SURCHARGE AMOUNt FEE CODE RECEIPTN 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(3-2-120) <br /> �,..� DATA PROCESSING COPY ti,/ <br />