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STATE OF CALIFORNIA W �4 ©F <br /> ATEA RESOURCES CONTROLARD �5�~ F•. <br /> FORM `A': r4 Asa <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY W PERMIT 3 RENEWAL PERMIT S CHANGE OF INFORMATION <br /> ONE ITEM 7 PE Y CLOSED SITE <br /> 2 INTERIM PERMIT 4 AMENDED PERMIT B TEMPORARY SITE CLOSURE <br /> +:7 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) I Q <br /> CAR OFjkOtlPjSSINFORMATICN <br /> Ab TiESyS <br /> NEAREST ROSS ST N <br /> ` ✓Bar to indicate ❑ LOCAL-AGENCY <br /> Q STAT€-AGENCY <br /> •�+ ❑ COARDRA7IGN ❑ LOCAL-AGENCY ,DERAL. ENCY <br /> CITY ME ❑ INN IDIIAL ❑ COUNTYAGENCY <br /> �}f� ST ZIP {7p e SITE P ONE 0,WITH AREA CODE <br /> CA Z D UL'1 1 - t)00 <br /> TYPE OF BUSINESS: F_�2 DISTRIBUTOR ::: <br /> OCESSOR ✓BoxifINDIAN �( EPA ID a <br /> 1 GAS STATION � 3 FARM THER <br /> RESERVATION <br /> DS ar LJ #of TANK's <br /> AT THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERG NCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST)1 77- PHONE k WITH AREA CODE DAYS: NAM' LAST,FIRST) <br /> /1� PHO #WITH AREA CODE <br /> NIGHTS: NAME{LAST FIRS r ��' <br /> PHONE Of WITH AREA CODE NIG TS: E(LAST,FIRST) PO#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE pF Ap R S INFORMATION <br /> MAILING Or TR T.A�pRESS ✓Box to indicate ❑ 'PARTNERSHIP ❑ STATE-AG NCY <br /> //��{ ❑ CORPORATION ❑ LOCAL.-AGENCY FE AL ENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMEQ S TE ZIP 0 PH'ON .1 ITH AREA CODE <br /> jr 4 IA <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE OMPLETED) <br /> NAME CARE DF AD RES S INFORMATION <br /> 14 <br /> MAILING O,f T DDRESS ✓Bo to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 1�{ ❑ CORPORATION ❑ LOCAL-AGENCY ❑ E ERA AGENCY <br /> - ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME ST1,4 YE ZIP COp PHON IT <br /> IV. <br /> 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: L 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# #of TANKS at SITE <br /> 5 � � [ � � ? lo6a3 <br /> CURRENT LOCAL AGENCY FACILITY ID# AP R E YI � PHONE#WITH AREA CODE <br /> PERMIT NUMBER PER TA P VA DA E ER <br /> L� � Lp�� PERMIT EXPIRATION DATE <br /> LOCAT N CODE CENSUS TRACT k SUPE/^R(f VISOR- I T T CODE BUSINESS PLAN FILED DATE {LED <br /> YES NO L/I <br /> CHEC k PE IT AMOUNT SURCHARG AMOU T FEE CODE RECEIPT# _T <br /> BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATIONI UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORMA(3-2-88)r t <br /> DATA PROCESSING COPY <br />