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STATE OF CALIFOR <br /> N& WATER RESOURCES CONTRBOARDro, <br /> zE^` `11 <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM a �', <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> E <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Efr7 PERMANENTLY CLOSED SITE W <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O � <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 00 <br /> FACILITY/SITE NAI <br /> hor . ( r <br /> CARE O DDREShS INFORMATION <br /> m I te eQ 11't. <br /> ADDRE ^ (' N REST CROSS STREET ✓But0lilaR 11PARTNENRIIP ElSTATE-AGENCYOO OC kQ YC0RPCROTIGN ❑ LIXALAGENCY ❑ ffpERAL-AGENCY <br /> v1 Ct.(I p1v Yl.t G-- ❑ INDMDUAL ❑ COUNTY AGENCY <br /> CITY N�EOd ) STATE ZRCO SITE PHONE p,WITH <br /> A AREA CODE <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Boz if INDIAN EPA ID If <br /> RESERVATION or If of TANK's <br /> ❑ 1 GAS STATION ❑3 FARMOTHER TRUSTLANDS ❑ ATTHISSITE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) _I^,I '\PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 1 W v <br /> NIGHTS NAME LAST,FIRSL) PHONE#WITH AREA CODE NIGHTS. NAME(IASLFIRS ) PHONE#WITH AREA CODE <br /> r("Jtle— U <br /> II. PROPERTY OWNER INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> NAME CARE OF AD SS INF RMATION <br /> Tern —hov e I ( c r <br /> MAILING 9L4TREET ADDR SS ✓ 10 indicate 1:1 PARTNERSHIP 11STATE-AGENCY <br /> y �1 YSCORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ,\ 1 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAMEO ( ST ZIP Zd`( 0_QODE PHONE p,WITH AREA Ctor) <br /> III. TANKILOWNER INFORMATION &ADDRESS— (MUST BE COMPLETE(D) <br /> O/�) ��J of�t2iPCG' <br /> NAME CARE OF ADDRESS INFORMATION <br /> C <br /> MAILING or STREETADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ❑ it. II, <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# JURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE <br /> E�� OI I IEEZ2 I d 010101 <br /> CURRENT LOCAL AGENCY FACT ITS'ID* (00 APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER U In`,PEP <br /> )RMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATI N C DE CENSUS TRACT N SUPERVISOR DIS CODE BUSINESS PLAN FILED D TE F D <br /> YES ❑ NO E] I /S <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPTa 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 \ <br />