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t <br /> STATE OF CALIFORNI* WATER RESOURCESCONTROL40ARD <br /> „ <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM V �o <br /> SITE F ILITY/SITE, INFORMATION and/or PERMIT APPLICATION m Io <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `^•�.oe�`" <br /> MARK ONLY EW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 ANENTLY CLOSED SITE I-& <br /> ONE ITEM 2 INTERIM PERMIT ❑/AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE CD <br /> O <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) QQ <br /> FACILITY/SITE NA 'v„ <br /> E �AMIAi CARE OF ADDRESS INFORMATION vv <br /> QAdlAJ0 <br /> ADDRESS �• NEAREST CROSS STREET ✓gmbiEiuk ❑ GAAiNEASIIV ❑ STATE-AGM <br /> O M(5 0 COWFWA ON ❑ IOcu AGENLT ❑ RDSKAGDO <br /> 0 IND IX" ❑ WUNIYiGENCI <br /> CIN NAME STATE ZIP CODE SITE PHQNE N,WITH AREA CODE <br /> �� �L/f ��� O/ <br /> 1�ww CATYPE OF BUSINESS: ❑2 DISTRIBUTOR / SSOR I ✓Box B INDIAN EPA ID N <br /> RESEVATION❑ I GASSTATION ❑ 3 FARM 5 OTHER TR ST(LANDS w ❑ N o1 <br /> AT THHISIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DA6NAME( ,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> �1K j eNln 6' o 4/ <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CAR OFADDREBSI ORMATION <br /> �olwa v £�0 <br /> MAILING or STREET ADDRESS x to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> /N'�� CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> F� 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> �tt�0 0 y Od—aoP _ P <br /> Ill. TANK OWNER INFOR ATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> t1� <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME 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) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY R FACILITY ID N R of TANKS N SITE <br /> ® Id D 6 <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED <br /> BY NAME PHONE N WITH AREA CODE <br /> W eJ <br /> PERMIT NUMBER PERMIT APPROVAL DATE ai PERMIT EXPIRATION DATE <br /> -';--/7-07 <br /> LOCATION ODE CENSUS TRACT If /'E SUPERVISOR-DISTRICT,CODE BUSINESS PLAN FILED DATE FILED <br /> 2 TO Gv YES ❑ NO ❑ <br /> CHECK PERMIT AMOUNT SURCHARGE 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 /> wv\\\1 FORM A(3-2-BS) <br /> �.x,,. DATA PROCESSING COPY <br />