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STATE OF CALIFORNI WATER RESOURCES CONTRAOARD <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 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 2-1_CHANGE OF INFORMATION ❑ 7 PERMANENTLY G D SITE I"� <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N <br /> 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) ~ <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> f�iliZ <br /> ADDRESS NEAREST CROSS STREET ✓ rdi-1 ❑ PARTNERSITY ❑ STATEAGENCY <br /> 0�J CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> (/ �- ❑ INDIVIDUAL ❑ COUNIKAGENCY <br /> CITY NAME STATE ZIP CO € SITE PHONE a,WITH AREA CODE <br /> CA j3 y - <br /> TYPE OFBUSINESS: =2 DISTRIBUTOR ❑ 4PROCE I/Box ii INDIAN EPA ID #of TANK's <br /> ❑ 1 GAS STATION 3 FARM ER RESERVATION or <br /> ❑ TRUST LANDS ❑ /JL%(Jll✓C./ 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 P WITH AREA CODE <br /> S I ,tl d S9 'S`// <br /> NIGHTS: NAME(LAS FIRST) PHONE a WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE P WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> /0�61w_ � <br /> MAILING or STREET ADDRESS ✓Box toirrcicale ❑ PARTNERSHIP ❑ STATE-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 /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS -/Box lointlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a.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. I. ❑ If. ❑ <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 /> U v O <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT 0 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIIAD <br /> D.�r a3-0�0 YES [:] NO E] l/ /r f <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE 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 ON Y. <br /> IFORM A(3-2-88) <br /> DATA PROCESSING COPY 0 <br />