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STATE OF CALIFORNO WATER RESOURCES CONTRIPBOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM �^ <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> m <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Ej 5 CHANGE OF INFORMATION 7 PERMANENTLY LOSED SITE <br /> ONE ITEM I & <br /> 21NTERIM PERMIT �q AMENDED PERMIT � 6 TEMPORARY SITE CLOSURE <br /> 00 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) CD (0 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> �K <br /> ADDRESS <br /> �� ^�' NEAREST GROSS STREET ✓Sm tondnEiGle ❑ PARTNERSHIP ❑ STATE AGENCY <br /> cl I C� K ❑ INDIVIDUAL ❑ COUNTY AGENCY FEDERAL AGENCY <br /> CITY NAME • STATE ZIP CODE <br /> O SITE PHaE ITH AREA CODE <br /> CA <br /> TYPEOFBUSINESS: p DISTRIBUTOR E:[4 PROCESSOR ✓Box ii INDIAN EPA ID a <br /> El I GASSTATION FARM OTHER RESERVATION or ❑ y_ - Bof HISSITANK'sQ <br /> TRUST LANDS {"(�`y(;Q� AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS' NAME(LA T FIRST) PHONE p WITH AREA CODE DAYS. NAME(LAST,FIRST) <br /> Ile <br /> /��114 ( PHONE ft WITH AREA CODE <br /> NIGHTS: NAME( FIRST) u PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME ( <br /> S�YYL2. QJ S/ �� CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 13 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE <br /> PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S awr.2 Gc S S <br /> MAILING or STREET ADDRESS ✓Dox to,ndicate ❑ PARTNERSHIP <br /> Cl STATEGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY <br /> FEDERAL-AGENCY L-AGEN <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCYFEDERAL-AGENCY <br /> CITU NAME <br /> STATE ZIP CODE PHONE N,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. 11. 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 8 SIGNATURE) PATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION k AGENCY R FACILITY ID k k of TANKS at SITE <br /> � `fav o Eo � d <br /> CURRENT L C AGENCY FACILITY ID x APPROVED BY NAME <br /> �F /'/ PHONE M WITH AREA CODE <br /> PERMIT NUMB/ER �J PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3' �- YES NO / O <br /> CHEgk# I PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT K !J <br /> 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- 1 <br /> FORM A(32-SS) <br /> W1 -�`OD 4� DATA PROCESSING COPY <br />