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STATE OF CALIFORNIA WATER RESOURCES CONTROLYOARD of <br /> c� r <br /> FORM 'A': <br /> M <br /> UNDERGROUND STORAGE TANK PROGRAM �p <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -,�'o;ta P T <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANE CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> Cn <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> Cr'I <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> r r Q <br /> ADDRESS NEAREST CROSS STREET ✓Box to rdrAe Cl PARTNERSHIP ❑ STATE.AGENCY <br /> WORATION 1:1 LCA-AGNCY ❑ FEDRAL-AGENCY QKN <br /> �ngINDIVIDUAL ❑ CXNN-AGENLY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> t, CA 2 -z3 -2fa o <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑4 PROCESSORBox R IND AN EPA ID N <br /> RESERVATION or ` � #of TANK'a <br /> I GAS STATION ❑3 FARM R 5 OTHER TRUSTLANDS ❑ lam' AT THIS SITE 0 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> N k `2��G �IQtrPni �Z3 --26�( <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME:(LAST,FIRST) PHONE N WITH AREA CODE <br /> r <br /> i <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NA! '� CARE OF ADDRESS INFORMATION <br /> J�T l< <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#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> N CARE OF ADDRESS INFORMATION <br /> � ads <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#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS 05 <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 TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> LL—ILI I 1FO -Allo/ 1 ' <br /> 3 FO-10101:01 <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED <br /> 2 ?1 � YES [:] NO <br /> CHECK PERMIT AMOUNT SURCHAARCZE AMOUNT FEE CODE RECEIPT N BY: <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 /> `` DATA PROCESSING COPY WOO <br />