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STATE OF CALIFORNb� - WATER RESOURCES CONTRCt4OARD sEx'"" <br /> 4. <br /> FORM `A': `` �"�" <br /> UNDERGROUND STORAGE TANK PROGRAM # • <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> ell, <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE �""`OP"'/ <br /> MARK ONLY V ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE FcwZ <br /> 10 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> HEY 0C NOr1c N <br /> ADDRESS NEAREST CROSS STREET ✓Bm to itMirae ❑ PARTNERSHIP ❑ S7 EAGENCY <br /> ❑ CORPORATION ❑ LOCALAGENGY ❑jNER4L AGENCY <br /> 2 J b• L ❑ INDIVIDUAL ❑ COUNTY AGENCY 1/ <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> .r CA Z,- NE <br /> TYPE OF USINESS. ❑ 2 DISTRIBUTOR F__] 4 PROCESSOR ✓Box,t INDIAN EPA IO # #of TANK'# <br /> 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTY <br /> ATION LANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> IIS S 4 -804 015Fr1✓ <br /> NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> E <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> W.6 I L-L O n)is <br /> MAILING ar STREET ADDRESS ✓Box to Indicate Cl PARTNERSHIP ElSTATE-AGENCY <br /> C ❑ CORPORATION LOCALAGENCY11DERAL-AGENCY <br /> 2, S, El INDIVIDUAL ElCOUNTY-AGENCY <br /> CITY NAMESTATE ZIP CODE HONE#,WITH AREA CODE <br /> -so 49 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S. Cri LL- IN'l o iJE <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 2 ❑ CORPORATION ElLOCAL-AGENCY ❑ �DERAAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY ✓ L- <br /> CITY NAME STATEZIP CODE PHONE#,WITH AREA CODE <br /> fj s <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. ❑ If. ❑ 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 B SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 2E = = I oo I I e o I Doo 16 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> (�, ( t_L. 1 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE LED <br /> YES p No ❑ $ 3 $ <br /> CHECK PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Y: <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 /> \v FORM A(3-2-88) <br /> DATA PROCESSING COPY �/ <br />