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STATE OF CALIFORNIA'" WATER RESOURCES CONTROvid RD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM t *�" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EAC2 FACILITY/SITE `'��•�^=" <br /> FMARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE65 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) r <br /> F+ <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 6e M r c kcs cT <br /> ADDRESS NEAREST CROSS STREET ✓Bmttator ❑ PARTNERSHIP ❑ MAU AGFACY I <br /> S.— r 11 WPPORATION 13 LOCAL ❑ RDML AGENCY <br /> L ❑ INDNDML 0 COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> AION+e2_0� CA 95 <br /> ? 336 <br /> TYPE OF BUSINESS: ❑2 ISTRIBUTOR ❑ 4 PROCESSOR ✓BoESERx ii INDIAN EPA 10 R <br /> ❑ 1 GASSTATION 3FARM ❑ 5OIf of TANK's <br /> THER ION <br /> TRUSTMLANDS ATION or ❑ ATTHISSRE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE If WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAM ,4,05(74; <br /> CARE OF ADDRESS INFORMATION <br /> orc <br /> MAILING or STREET ADDRESS ✓Box toiotlicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> .b CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> E. 'v ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CI NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> e,� 1 9526 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NA CARE OF ADDRESS INFORMATION <br /> 0_,r <br /> MAILING or STREET ADDRESS ✓Box to inciicate ❑ PARTNERSHIP C STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK 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 R JURISDICTION K AGENCY N FACILITY ID R K of TANKS BI SITE <br /> EY] E:= / a <br /> CURRENT LOCAL AGENC�AIC/W/TC ID N f�/� APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER •(/- `//� Ir—T(PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA IONCODE CENSUSTRACTX SUPERVISOR-DISTRICTCODE BUSINESS PLAN FILED GAT/E FIVO <br /> '2 2 S— YES NO b ,S <br /> `A / CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> VV 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 /> FORM A(3-2-5&) <br /> DATA PROCESSING COPY <br /> I <br />