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art <br /> STATE OF CALIFORNIP WATER RESOURCES CONTROL OARD <br /> W' <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM = " o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'Q,F�a."-`! <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 50 00 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) cn <br /> 00 <br /> FACILITY/ NAME CARE OF ADDRESS INFORMATION <br /> eI [a <br /> ADDRESS NEAREST CROSS STREET %/Em to irAicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> 0(p�1 3 U n o, 1 1_ I cL VA� �1 tA �IVPDRA➢ON 11 UAL 11CO COUNTY AGENp ❑ FEDEMI-AGENCY <br /> CITY NAME -Y F STATE ZIP CODE SITE PHONE ft.WI H AREA CODE <br /> CA q 3 LPLA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID# <br /> ❑ RESATION <br /> I GAS STATION [:] 3 FARM -OTErR TRUSTVLANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. 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 ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CIN NAME STATE ZIP CODE PHONE#,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. if. ❑ 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 If AGENCY# FACILITY ID# #of TANKS at SITE <br /> IDID12121qlqlao <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> C G 0-In I <br /> PERMIT NUMBER PERMIT APPROVAL DATELICE <br /> PERMIT EXPIRATION DATE <br /> LOCATION C DE CENSUS TRACCT7# SUPERVISOR-DISTRICTBUSINESS PUN FILED D TE FILED <br /> G <br /> D a�C D q �IYES ❑ NO ❑ W I I —) - 0 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNTODE RECEIPT At 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) <br /> DATA PROCESSING COPY <br />