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STATE OF CALIFORNIA,.- WATER RESOURCES CONTROtiOOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION aZo <br /> G COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��xo•x" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I_& <br /> ONE ITEM ❑ p INTERIM PERMIT ❑0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 4 <br /> Lrl <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) 0) <br /> CO <br /> FACILITY/SITE NAME CARE OF ADDRESS�FORMATION <br /> h � seru,ce e.� fer LI owl, &(Ams <br /> ADDRESS AR <br /> p NEAREST CRO TREET nEiuk F1PARTNBEIIIP El STATE AGENCY <br /> Q Gr►e kt+` + �Q� RATION 11 IGCALAGENCY El R-GERLL.)IC{NCY <br /> IO <br /> LLLLLIIIII INOMWAL ❑ 001.11WAGENCY <br /> CITY N ME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> COCCL CA O - 3 go SO <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑d PROCESSOR -/Box If INDIAN EPA ID N <br /> RESEVATION <br /> i GAS STATION ❑3 FARM ❑5 OTHER TRUST LANDS or 1:1Mol TANK'S <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> nls I-ImKl ROT— - UKH <br /> NIGHTS: NAME(LAST,FIRSI) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> (lMlS - 3 - U N <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME�-,,""' / CARE OF ADDRESS INFORMATION <br /> ,�(,Wp2 QS ,� <br /> MAILING or STREET ADDRESS ✓Box toind,cate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME ! CARE OF ADDRESS INFORMATION <br /> as - l <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <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: 1. 11. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY R FACILITY IDR R of TANKS at SITE <br /> 10101 i 1010 101-01 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> .� I YES Ni OL 6 C�l <br /> CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: <br /> �IlkTHIS FORM MUST BE ACCOMPANIED BY AT LEAST;!)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-SS) <br /> SNA DATA PROCESSING COPY AST <br />