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111119111 -Ir A R <br /> STATE OF CALIFORNIA WATER RESOURCES CONTR•OARD P sE. <br /> Vis_' '; <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> GCOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY El 1 NEW PERMIT ♦� <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ,j r <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) C <br /> FACILITY/SITE.NAME CARE OF ADDRESS INFORMATION <br /> -�rrr k R (' do IlAal <br /> ADDRESS NEAREST CROSS STREET El CORPORATION ❑ LOCAL AGENCYSHIP El STATE <br /> AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> S0� N CA <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box rf INDIAN EPA 10 It #of TANK's <br /> RESERVATION or AT THIS SITE <br /> ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIM RY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS' NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> NIGHTSNAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LPST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box tolndicale C3 PARTNERSHIP ElSTATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN 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. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION Is AGENCY# FACILITY ID It It of TANKS at SITE <br /> F-FT/JilZO FT= <br /> CURRENT LOCAL AGENCY FACILITY ID k <br /> APPROVED BY NAME PHONE At WITH AREA CODE <br /> J<L 33 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CNSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> ^1 <br /> CHECK# PERMIT AMOUNT SURCHARGE MOUNT FEE CODE YES ❑RECEIPTIMO ❑ �BY;C-4 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEASOR MORE TANK PERMIT FORM 'B'APPLICATION(S),UbSS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) • '/�,✓ \ <br /> DATA PROCESSING COPY ^6 <br />