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STATE OF CALIFORNIA WATER RESOURCES CONTRAOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM V <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> L <br /> ADDRESS T/— NEAREST CROSS STREET ✓Bortkdi 0 PARTNBMIIP 0 STATE-AG00 <br /> O_ CL�BRBION 11LOCAL-AGOU 0 FM&W.-AGRO <br /> L1 DI WIINTY-AGBICY <br /> CITY N ME STATE ZIP CODE TE PHONE N,WITH AREA CODE <br /> CA O ao 9s�� 9/80 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ' <br /> INDIAN EPA ID N <br /> ❑ I GAB STATION ❑3 FARM �,FBTHER TRUSTYATIONIANDS Gr If of TANK's <br /> ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREACODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NI HTS: NAME(LAST,FIRST) HONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATIO ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST'AE COMPLETED) <br /> NAME C E OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓B toindicete 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CO ORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0INON AL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If,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 NOTIFICATIO ND BILLING: I. ❑ II. ❑ 111. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY XkOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) TE <br /> LOCAL AGENCY USE ONLY <br /> CrnNTY N JURISDICTION N AGENCY N FACILITY IID# N oR TANKS at SITE <br /> '+ <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 SUPERVISOR-DIIITRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 77-77 YES ❑ NO ❑ p7oZ �� <br /> CHEC N PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-18) <br /> �,� 5— 3a'Ajo 0 <br />