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M- <br /> STATE OF CALWORNG"- WATER RESOURCES CONTROwISOARD any <br /> =�La .D <br /> FORM `A`: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 1 NEW PERMIT ❑3 RENEWAL PERMIT <br /> ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE <br /> MARK ONLY <br /> ONE ITEM 2 INTERIM PERMIT E] 1 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> ❑ <br /> 1.FACILITY/SITE INFORMATION A ADDRESS— (MUST BEGCOMPARE OF L COMPLETED)NATION <br /> FAGIJTY/SfTE NAME '/ �'pn/C/I <br /> NCl/ ✓BMI4il#NN ❑ PAHlIE7M'P ❑ SfAiE-NTfCY <br /> NEAREST CROSS: D DLock.,Ara,Y D FMIAL-AWO <br /> ADDRESS Dive 11N ❑ ma Y!ffiICi <br /> STATE ZIP CODE SITE PHONE M.WITH AREA CODE <br /> CITY"ME CA 9S2 26 .2 33 -S�Brff <br /> TYPE OF BUSINESS: 177 2 DISTRBl1TOfl 1 PROCESSOR ✓BDA if INDIAN - <br /> ❑ ❑ EPA IDM ET TIS SITE RESERVATION Or ❑ AT THIS SITE <br /> ❑1 GASSTATION [j7�63 FARM ❑5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(SECONDARY) <br /> EMERGENCY CONTACT PERSON(PRIMARY) <br /> DAYS: NAME(UST.FIRST) <br /> PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> "X, Chrnk PHONE M WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(UST.FIRST) <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> e os 1 <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION III ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> e as 1 <br /> MAILING or STREET ADDRESS ✓Boz toinoicala D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION Cl LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. II. ED NI.❑ <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 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYJI JURISDICTION N AGENCY# GILfTV�D-IL_ "��, M of TANKS at SITE <br /> CrIENT LOCAL AGENCY FACILITY ID APPROVED BY NAME- PHONE#WITH AREA CODE <br /> CW <br /> PERMIT NUM RMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-0ISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3. ;Z.2 3 a.� YES NO � S <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 /> Gw. <br /> FORM A(3-2-88) _ <br /> w a - q � I <br />