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STATE OF CALIFORNI10 WATER RESOURCESCONTR4PBOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to <br /> CCOMPLETE THIS FORM FOR EACH FACILITY/SITE on <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE O, <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) CD <br /> O <br /> FACILITY/SITE NAME CAR OF ADDRESS INFORMATION <br /> E E #� - <br /> ADDRESS N EST CROSS STREET ✓suion*aN IABNp ❑ GTATE-Aev <br /> '7 �! ❑ COfd WTION p❑y1.0r, GENIX ❑ MEIULAGDNY <br /> G G ❑ INDMWAL Cg1NttAGENC! <br /> CITY NAME STATE ZIP CODE SITE 0 E N,WITH AREA CODE <br /> CA q52-07-- <br /> TYPE OF BUSINESS: F__j 2 DISTRIBUTOR F__j 4 PROCESSOR I ✓Box if INDIAN EPA ID N <br /> 1 GAS STATION ❑ 3FARM OTHER TRUST LANDS RESERVATION or ❑ ATT IS SITE OZ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FI T) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Mm e 9 -82 / <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS:_{AME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAl+tf� CARE OF ADDRESS INFORMATION <br /> MAILIN or STREETADDRESS ✓Box to indicate OJ PU�AATNERSHIP 11 STATE-AGENCY <br /> ElCORPORATION C3'LOCAL-AGENCY 13FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAM <br /> ESTATE I ZIP CODE JRHONEp,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> �— <br /> MAILING or STREET ADDRESS ✓Box to intlicate ❑ B#IfRRTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION E3'LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> IV ( V ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,VITH AREA CODE <br /> bq 95Z0 Z 9 '9w-s'2, <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ I. El III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CO RECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID B N of TANKS at SITE <br /> uEl = d o0 <br /> CURR`R TT LOCAL AGENCY FACI IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> V/ / <br /> PERMIT# MBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE I� <br /> LOCATION CODE C�STRACTN SUPE VI$7DISTRICT CODE BUSINESS PLAN FILED NO DATE <br /> %E <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 ONLY <br /> FORM A(3-2-88) J` <br /> DATA PROCESSING COPY <br />