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STATE OF CALIFORNIP WATER RESOURCESCONTROL41OARD <br /> M1 SEP` �f <br /> FORM A: V. , <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ? .� 1 <br /> COMPLETE THIS FORM FOR EACHILITY/SITE <br /> FA <br /> �'/��_"`` <br /> MARK ONLY r_-] 1 NEW PERMIT F—] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYC SElyprx <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ��✓✓ <br /> IC <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Box to mmrate ❑ PARTNERSHIP ❑ STATE AGENCY co <br /> ❑ CORPORATION ❑ LOCALAGENCY Cl FEDERAL- <br /> AGENCY <br /> L L ❑ INDIVIDUAL ❑ couNn.AGENcr <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> S CA QS 02 <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> RESERVATION or X of TANK's <br /> ❑ i GASSTATION [:j3 FARM �5 OTHER TRUST LANDS ❑ 1 AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(IAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST( PHONE#WITH AREA CODE <br /> NIGHTS. NAME(UST,FI ST) PHONE a WITH AREA CODE NIGHTS _TAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> Sfi"-lc <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OFBURRESS INFORMATION <br /> I IC'N <br /> MAILING or STREETADDRESS ✓Bax to indicale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ �C�JRRPPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 4 INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE q,WITH AREA CODE <br /> I's Z02 I -- <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME rp CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �j L ❑ C PORATION D LOCALAGENCY ❑ FEDERAL-AGENCY <br /> p �', i/ NDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME 1 STATE ZIP CODE PHONE a,WITH AREA CODE <br /> %J <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. ❑ 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# #ot TANKS at SITE <br /> La L3 I eA(j 10 % <br /> CURRENT LOCAL AGENCY FACILITY ID# APP D Y NAME PHONE#WITH AREA CODE <br /> S U <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> ATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> O/ 'l3 YES NO <br /> CK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# I BY: aaaaaar <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 />