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STATE OF CALIFORNlrcSOURCESCONTROLfBOARD <br /> FORM `A': UNDERGRO AGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFOR ION and/or PERMIT APPLICATION Z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `+i FOL�+`�I`p 10 <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I-& I <br /> ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) A <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION µ <br /> G e e W�k/tis C ..re <br /> ADDRESS NEAREST CROSS STREET ✓Bw Nroar 0 PARINDiSyW 0 STATE AGENCY 6-5cLI(QN -R� AL � ❑ COWOMTION [ILOC&AGENT ❑ FEDEPAL-AGENCY <br /> CITY NAME 0 WIN= 0 WUNtYAGENCY <br /> STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> L/A.13�pF✓ CA -�7 - <br /> TYPE OF BUSINESS ❑3 DISTRIBUTOR ❑ 4 PROCESSOfl ✓Box if INDIAN EPA IDN <br /> ❑ I GAS STATION [V3 FARM ❑5 OTHER RESERVATION o ❑ N of TANK'N <br /> TUST LANDSAT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> tisto? -W?-353rl <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> VO4,1-5 <br /> kfnL 2aq-M-3537 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to i,dicat. 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION 11, <br /> MAILING or STREET ADDRESS ✓Boa to in0icale 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY - <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS leol <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 9 II. ❑ 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 N JURISDICTION N AGENCY R LIITT - R of TANKS at SITE <br /> gPERM !t <br /> LITY ID N /� APPROVED BY NAME PHONE N WITH AREA CODE <br /> P\tK �PERMITAPPROVAL DATE PERMIT EXPIRATION DATE <br /> TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATEfIIEq <br /> ';2� YES NOMOUNT SURCNILRGE AMOUNT FEE CODE RECEIPT N BY: <br /> THIS FO M 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 /> FORM A(3- BB) II <br /> DATA PROCESSING COPY <br />