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STATE OF CALIFORNI? WATER RESOURCES CONTRAOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM em <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r' <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT ler,5 CHANGE OF INFORMATION <br /> ONE ITEM 2 INTERIM P ❑ 7 PERMANENTLY CLOSED SITE <br /> ❑ PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ( / <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATI <br /> {PQ c K" vt (�(� <br /> ADDRESS `/��Y/ NEAREST CROSS STREET ,.✓, oroiute ElPARTNEASHIP ❑ <br /> STATE N <br /> (J CORMIlATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY ENC `4 <br /> CITY NAME STATE ZIP CODE / S��HONE#,WITH AREA COpF�Q <br /> CA l? <br /> TYPE OF BUSINESS 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> ❑ 1 GAS STATION ❑ 3 FARM .OTHER RESER LA ION o ❑ #of TANK's / <br /> / iltTYL- AT THIS SITE ! <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA pCODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> �Qrr " n �r (ao9 Lf77-dlo 4/ <br /> NIGHTS: IE(LAST ST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 3 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME ^' ^^^ CARE OFADDRESS INFORMATION <br /> MAILING oT STREET ADDRESS ✓Box to ind,,,.e ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Ll ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTVAGENCY <br /> CITU NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY❑ INDIVIDUAL 11COUNTY-AGENCYCITY NAME STATE ZIP CODE PHONE k,WITH AREA GODE <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. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID At #of TANKS e1 SITE <br /> oa & � I / <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 4 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT(## SUPERVISOR-DISTRIC CODE BUSINESS PLAN FILED DATE FILED <br /> v/ �3• O v / T YES E NO --t G <br /> CHECK p PERMIT AMOUNT SURCHAgGE AMOUNT FEE CODE RECEIPT If I BY O UUU <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 /> FORMA(3-2-BS) <br /> • DATA PROCESSING COPY I <br />