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STATE OF CALIFORNIk WATER RESOURCES CONTRGwBOARD o. <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SIT"61 INFORMATION and/or PERMIT APPLICATIO o �� o <br /> G' COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 P MAN CLOSED SITE F"a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) ~ <br /> A <br /> FAC SITE NAME �' � CAREO ADDRESS INFORMATION <br /> r^O <br /> ADDRESS , NEAREST,pP SSTREET ✓ftwiddl, ❑ PMTNE/EHIP ❑ SIARAGENGY <br /> MTO ❑ CEy ❑ R7EW AGDOO INDMi <br /> CIN N KTAATl' <br /> ZIP CODE SITE PHONE p,WITH AREA CODE <br /> CA S ZZ .o4 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 OCESSOR ✓Box M INDIAN EPA IO p <br /> RESERVATION or ❑ NoI TANK'a <br /> ❑ 1 GAS STATION ❑ 9FAflM SOTHER TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EME GENCY CONTACT PERSON(SECONDARY) <br /> DA NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NA (LAST,FIRST) PHHO p WITH AREA CODE <br /> U <br /> NIGHTS'. AME(&T.FIRST) - PHONE p WITH AREA CODE NIGHTS: ME(LAST,FIRSTI PLAPE p WITH AREA CODE <br /> W-4 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAM A CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME /� CARE OF ADDRESS I RMATION <br /> S A <br /> MAILING Or STREEf;tDD�ES3 /� ✓Box to indicate �RTNERSHIP ❑ STATE-AGENCY <br /> V X S ❑ CORPORATION ❑ CAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL COUNTY-AGENCY <br /> CIN NAM STATE Z CODE PHONE ft,WITH AREA CODE <br /> Z2� <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. ❑ it. ❑ 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 M JURISDICTION R AGENCY R FACILITY ID M k of TANKS at SITE <br /> ® = = 101011 = 10d <br /> CURRnENT LOCAL AGENCY FAC ITY 10 N APPROVED BY NAME PHONE V WITH AREA CODE <br /> c- <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT p SUPERV S R-DISTRICT CODE BUSINESS PLAN FILEDDDAT(EE�fJ-FIILEO ) <br /> Z YES ❑ NO� 60P � Z3 <br /> CHECK♦ PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECENT BY: <br /> TENS 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 /> FORM A(3-2-88) <br /> �.d DATA PROCESSING COPY a� <br />