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STATE OF CALIFORNlir WATER RESOURCES CONTROMOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM = <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE o""°°"," <br /> MARK ONLY ❑ T NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT El 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSUREIII <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> F <br /> ADDRES NEAREST CROSS STREET ✓8ovb,xAuV ❑ PAHINENSHIP ❑ STATEAGENCY <br /> ❑ i101 ❑ LGCAL-AG90 ❑ FEGEWd AGENCY <br /> �EI� MG Al [I DOOM AGENCY <br /> CAP STATE ZIP CODE-�1 SITE PHONE N,WITH AREA CODE <br /> A CA ' 01 <br /> TYPE OF BUSINESS. ❑ 2 DIS BUTOR 4 PROCESSOR ✓Box B INDIAN EPA ID N N of TANK'L <br /> RESERVATION or � AT THIS SITE <br /> 1 GASSTATION FARM 5 OTHER TRUST LANDS <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 /> NIGHTS' NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST( PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME pv ) � CAPE OF ADDRESS INFORMATION <br /> rg <br /> MAILING o STREET ADDRESS ✓80x to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> y, ❑ CORPORATION ClLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> / ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> C y� <br /> Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> � A1.'4L vWvk710 <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,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. ❑ II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRU AND CORRECT. <br /> APPLICANT'S NAME(PRINTED S SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY S JURISDICTION R AGENCY N FACILITY ID R R of TANKS of SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> r <br /> LE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED GIb <br /> �1 A YES NO /a. � /may <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: <br /> 0) THIS FORM MUST BE A(C_D-D_MPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL <br /> FORMA(3-2-88) p `/ <br />