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STATE OF CALIFORNIP WATER RESOURCES CONTIROARD <br /> f <br /> ti_ A <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> v COMPLETE THIS FORM FOR EACH F LITY/SITE `'��•oa"" <br /> MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑7 P CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Bmbubal, ❑ PARMEXSNIP ❑ STATE-AGDO <br /> a 11CGRgPATIGN 13LOCAW ENGY ❑ FEGE/UI MM <br /> (/ ❑ INWDJAL ❑ COWIT-AGOI(Y <br /> CITY NAME STATE z0bose- / SITE PHONE N W Fj VEA CODE <br /> CA - <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR F-14 PROCESSOR ✓Box It IN IAN EPA IDN 6 F W TA/NNK's <br /> ❑ 1 GAS STATION 3 FARM 5 OTHER TRUSTYLANDS nr ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST,FIRST( �+ / PH NEN WITH ADAYS: NAME(LAST,FIRST PHONE#WITH AREA CODE <br /> NIGHTS: N (LAST,FIRST( 1G I 1 PHONE N WITH AUREA C DE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> 11. PRjdPERTY OWNER INFORMATION &ADDRESS—(MUST BE CO D) <br /> N ECARE OF ADDRESS INFORMATION <br /> �vvTes�- <br /> AIUNGor SIRE ADDRESS ✓Bon to indicate 11PARTNERSHIP STATE-AGENCY <br /> 11 CORPORATION 13LOCAL-AGENCY ❑ DERAL-AGENCY <br /> L O 4 O ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CI AME STATE ZIPOODEPHONE If,WITH REA CODE <br /> Zid <br /> III. TANK OW NFORMATIOfil &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ELE&SZNeRSFFip ❑ STATE-AGENCY <br /> ❑ CORPORATION LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,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. Ill. ❑ <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 N AGENCY S FACILITY ID k R o1 TANKS BI SITE " <br /> a6 0o © <br /> CURRENT LOCALJ�HIIICY FACILI ID0 APPROVED BY NAME PHONE M WITH AREA CODE <br /> 1- <br /> PERMIT <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT F SUPERVISOR-0187111 ODE BUSINESS PLAN FILED NO DATE FILLED <br /> CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM BY: ,- �P-2 <br /> 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(3-2-88) • • <br /> L <br />