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STATE OF CALIFORN11 WATER RESOURCES CONTR BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM e Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El 7 PERMANENT Y CLOSED SITE <br /> MA ❑ IV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE CD <br /> IV <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) C71 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ct 1 0 n Sro5 ' rum <br /> ADDRESS,5/ NEAREST CROSS STREET ✓CORPONzle 0 PARTNERSHIP 0 FEDERAGENCY <br /> AGEN <br /> ❑ CggFM ION 0 LOCAL AGENCY 0 STATEAGAGENCf <br /> 0 INNNIDNAL 0 COUNIYAGENC! <br /> CITY NAM �o STATE ZIP CODE SITE PHONE k,WITH AREA CODE <br /> CA JSo1 Q1 S <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a A o17ANK's <br /> RESERVATION or ❑ � AT THIS SITE <br /> ❑ 1 GAS STATION ❑ 3 FARM 3 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> IYl F e S ;3o r(dl 4 <br /> NIGHTS'. NAME(L�A,ST. <br /> _FIR'STT n PH NN N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 9 WITH AREA CODE <br /> WV I`�--� <br /> II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME }- �g CARE OF ADDRESS INFORMATION <br /> G /T /AV <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0-STATE AGENCV <br /> /� n I, 1 � / ❑ CORPORATION 0 LOCAL-AGENCY ;'0 FEDERAL-AGENCY <br /> f ((J G W 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITU NAME STATE ZIP C 216 PHONE p,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME Ry„� CARE OF ADDRESS INFORMATION <br /> &q 12 <br /> MAILING or STREET ADD SS �-//' ✓Box to indicate 0 PARTNERSHIP 0 STATE <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> C <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. ❑ it. ❑ 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 R JURISDICTION N AGENCY R FACILITY ID M S of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE <br /> 3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT X SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED NO <br /> ❑ DTE FILED <br /> a� - � a <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT It 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(3-2-88) 0 <br /> DATA PROCESSING COPY <br />