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STATE OF CALIFORNIAR OURCESCONTROL BOARD <br /> i <br /> FORM 'A': UNDER S AGE TANK PROGRAM �* <br /> SITE FACILITY/SITE, IN N and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FA ITY/SITE •�^"'" Fj/ <br /> MARK ONLY ❑ 1 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 I, a0 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION W <br /> e iv%c C�rif e/- ar�i� C�► <br /> ADDRESS / NEAREST CROSS STREET 0 Flo O 0 PAMELOMSHIP 0 STAETE AG GO <br /> orvlouu ENCY <br /> ❑ couim mvim <br /> CITY NAMESTATE ZIP CODE C s SITE PHONE#,WITH AREA CODE <br /> �h CPCCA 5 o TYPE OF OF BUSINESS: 2 DISTRIBUTOR ❑ 4 PPWCMR ✓Box if INDIAN EPA ID # <br /> RESERVATION or #of TANK'# <br /> E] 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ 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 /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> C m . er rYSes <br /> MAILING or STREET ADDRESSx to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 3 5 ;x e G Ave. 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> dcc- Q rrT C4 6�/ <br /> Ill. TANK OWNER INFORMATION & 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 ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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: I. ❑ 11. 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# #of TANKS at SITE <br /> m 9 � 3 o 00 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> L' /V/c iy <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3 a 3 a 3 `9v YES ❑ NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAS OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORM A(3-2-88) 1 w <br /> DATA PROCESSING COPY <br />