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v ' ^ . s- v. vI1r811 v. ..aA� pLNLP FIGJV VY�yLJ yVWNYiVL OVMFIV FORM `A': UNDERGROUND STORAGE TANK PROGRAM j SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE- 49 tMAtRKONLY:::E0l NEW PERMIT 3 RENEWAL PERMIT S 'GRANGE OF INFORMATION 10 7 PERMANENTLY CLOSED SITE 2 INTERIM PERMIT dAMENDED PERMIT 6 TEMPORARY SITE CLOSURE C.J Z I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION # 9y/cn ADDRESS NEAREST CROSS STREET ✓Bw NrdoK ❑ PMI6Di ❑ St.TEAmv Gn p { Gn O oC• Q-IIINY"A 13 [DIMY-I(s11LY F1 CO�Tft 13 L0CkAQD0 ❑ ROBW+IGENLY 00 CITY NAME STATE ZIP CODE TE PHONE S.WITH AREA CODE N CA Ss33 a 3w TYPE OF BUSINESS: F-] 2 DISTRIBUTOR E] N PROCESSOR ✓Boz N INDIAN EPA ID N I GAS STATION ❑3 FARM UJ3'GTHER RESERVATION txE] l' If of TANKN I TRUST LANDS 0 AZ& AT THIS SITE I EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,F STI P E M WITH AREA CODE DAYS: NAME(UST.FIRST) PHONE N WITH AREA CODE 100 NIGHTS: NAME(LAST,FIRST) P14ONE ITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE Of ADDRESS INFORMAyON SOY✓ -2�� S MAILING or STREET ADDRESS v ✓Sm to JiC.IB ❑ PARTNERSHIP ❑ STATE-AGENCY //�� ❑ ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY T DIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE 4i yohis 3 -7 0 111. TANK OWNER INFORMATION &ADDRESS—(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMAJI ,75�--,Me chi s,gmG MAILING or STREET ADDRESS ✓Box to i,o"I. ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY _, _ ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH A BOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. O�r III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYIN JURISDICTION If AGENCY E FACILITY ID N F of TANKS N SITE FTM = = lqlqlAc_ToT�] U o o v CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE 9 WITH AREA CODE 2 PERMIT NUMBER PERMIT APPROVAL DATEK^' prMITEXPIRATIONISACE V LOCA ODE CODE CENSUS TRACT N SUPERVI OR-DISTRICT CODE BUSINESS PUN FK.ED DATE FIIED 7 . a YES F] NO E S CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE pECE1PT E 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. FORM A 13-2-M) CDATA PROCESSING COPY `