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STATE OF CALIFORNIA <br /> FORM 'A'; WATER RESOURCES CONTROS <br /> SITE UNDERGROUND STORAGE TANK PROGRAM D _ 5 'iVo; l4f <br /> � / FACILITY/SITE INFORMATION <br /> y MATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY I NEW PERMIT - C <br /> ONE ITEM ❑3 RENEWAL PERMIT <br /> 2 INTERIM PERMIT ❑5 CHANGE OF INFORMATION <br /> I• FACILITY/SITE INFORMATION 4 AMENDED PERMIT 7 PERMANENTLY CLOSED SITE <br /> 6 TEMPORARY SITE CLOSURE r-j <br /> FACIL /SITE NA Ern & ADDRESS - (MUST BE COMPLETED) N <br /> ' ' 1 OD <br /> h) h CARE OF ADDR INFORMATION <br /> qn '1 <br /> ADDRESSm /� O <br /> QU NEAREST CROSS STREET K an <br /> CIN NAME ./o,-NDN <br /> COPW RAPON ❑ LOCAL gGFRCr. ❑ STTE-AGENCY <br /> STATE ❑ ININDAL ❑ COLWIYAGENCY ❑ FEDUAL.AGBICY <br /> TYPE OF BUSINESS: ❑ Z CODE SITE PHONE a,WITH AREA CODE <br /> 2 DISTRIBUTOR 0��4 PROCESSOR ✓BOX it INDIAN EPA ID qA 1 20 /\ <br /> ❑1 GAS STATION 3 FARM L� THEA RESERVATION or ❑ V L a <br /> EMERGENCY CONTACT Lam° TRUBT LANDS --^--� <br /> PERSON(PRIMARY) #of TANK's <br /> DAYS: NAME(LAST,FIRST) AT THIS SITE <br /> PHONE WITH AREA CODE EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) <br /> A <br /> NIGHTS: NAME(LAST, ST) PHONE#WITH AREA CODE <br /> PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> 11. PROPERTY OWNER INFORMATION III - PHONE#WITH AREA CODE <br /> "AME (MUST BE COMPLETED) <br /> MAILING or STREET ADDRESS CARE OF ADDRESS INFORMATION <br /> ✓Box to indicate ❑ PARTNERSHIP <br /> CITU NAME ❑ CORPORATION ❑ LOCAL-AGENCY ❑ STATFEDERALGNCYAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY- <br /> STATE ZIP CODE AGENCY <br /> III. TANK OWNER INFORMATION&ADDRESS- PHONE#,wires ARE#CODE <br /> NAME (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> MAIUNG ar STREET ADDRESS <br /> BOX to indicate <br /> O CORPORATION ❑ PARTNERSHIP <br /> CITY NAME ❑ INDIVIDUAL ❑ LOCAL-AGENCY ❑ STATE-AGENCY <br /> ❑ COUNTY-AGENCY ❑ FEDERAL-AGENCY <br /> STATE ZIP CODE <br /> PHONE q,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: L <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, II• ❑ III. <br /> AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION= AGENCY# <br /> ml FACILITY ID If If of TANKS at <br /> SITE <br /> CURRENT LOCAL ADENOY�CILITy 1D� (3 0- A U <br /> LI) �\I I("\r APPROVED BY NAME <br /> PHONE#WITH AREA CODE <br /> PEgM1T NUMBER PERMIT APPROVAL DATE ' <br /> PERMIT EXPIRATION DATE <br /> LOCATIO CQI`DE CENSUSTRACT# SUPERVIgOR-DISTRICT CODE <br /> BUSINESS PUN FILED <br /> DAJEf�(LED� <br /> CHECK# PERMIT AMSURCHARGE AMOUNT OUNT YES E3 NO M /'('/�\ I <br /> FEE CODE LYS J <br /> RECEIPT# 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 /> FORM A(3-2-58) <br /> 0 DATA PROCESSING COPY • <br />