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STATE OF CALIFORNO WATER RESOURCES CONTRIPBOARD <br /> , , � ' ,gym <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE / n I FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �; a <br /> 0 COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION En'7 PERMANENT�CEBSLH3SITE <br /> ONE ITEM El INTERIM PERMIT 11 ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �� v <br /> tl <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) p <br /> FACI /SITE NAME - . /- CARE,OF1 DORESS INFORMATION <br /> t /V�/✓/.�QgA.!/L� A/ <br /> ADDRESS /l /1 r1 q ,,,,�A /JE y, <br /> qNEARESTqCROSTTREEET, ❑✓Boxmmicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> r/V /`" x �t£'C,/l4Y'"_'� —'� � `-"' �I RPL TION ❑ LOUNlYAENGY ❑ FEDERAL AGENCY <br /> (J J\ NDIVDUAL ❑ LOCAL AGGENCY <br /> CITYNAME // P CEDE E PHONE#,WITH AREA CODE <br /> , Z`jb ) -�t6.71 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID If If of TANK's <br /> RESERVATION or AT THIS SITE 00 <br /> ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ CAL 0 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAY NAME(IFAST <br /> AST,FIRST) PH #WITH AREA CODE <br /> r ( g ,� A <br /> NIGHTS'. NAME(LAST FIRS- PH ON P WITH AREA CODE NIH^ h <br /> S : NAME(LAST.FIRST) E#WITH AREA CODE <br /> W // <br /> !.-..l rN <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> CARE OF ^DDRESS INFORMATION <br /> N <br /> /% w <br /> MAILING or STREET ADDRESS /, ✓Box to Indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> \��L}. ❑feORPORATION ClLOCAL-AGENCY ElFEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY N ME STATE ZIP CODE HONE# WITH AREA CODE <br /> (_o1),' r A s' z� z- <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Q <br /> MAILING or STREEf ADDRESS ✓Box <br /> CORP RATIte ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTV-AGENCV <br /> CITY NAME STATE ZIP CODE PHONE p.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> FCHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. 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# AGENCY# FACILITY ID# If of TANKS at SITE <br /> CURRENT�LOCAL <br /> ��A�� FACILITY 10# LAED PHONE#WITH AREA CODE <br /> ft <br /> PERMIT NUMBER t <br /> OVAL DATEj <br /> MI EXPIRATION DATI <br /> LOCATION CODE CENSUS TRACT# UPERVISOR- INESS PLAN FILED ATE ILED <br /> Z 3. F/S ? YES NO 6 (� f5CHECK# PERMIT AMOUNTURCHARGE RECEIPT# BY <br /> 1 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 /> \,p1111 FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />