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STATE OF CALIFORNIO WATER RESOURCES CONTRONOARD �oF <br /> E�, l" <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM Imo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACHFATY/SITE <br /> MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El PERMANENTLY CLOSED SITE <br /> ONE ITEM <br /> ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME /�,�Q CARE OF ADDRESS INFORMATION <br /> ADDRESS ���, NEAREST CROSS STREET ✓Box to indrale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> / �O/1 .� %GJ�O/)Hyl��� /9 Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> / h! (9 / l/' 4i ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> NAME _ j STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> !� f ' CA <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N It of TANK'>< <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTTVLANDS ATION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE k 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 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> y/..3A ,/� ❑ CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> 4J / U/Y� �/ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME L STATE ZIP CODE PHONE N,WITH,AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> -5G'Lrn...-r Q J <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. ❑ it. ❑ 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 8 JURISDICTION M AGENCY N FACILITY ID ft N of TANKS at SITE <br /> 1_7`�- 1 1 1 1 J EI I I L-1- I I I _L] 10 16 P� <br /> CURRENT LOCAL Aq&NCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> r Vr//e r41 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 9 9 Z 7 � 2�- j YES ❑ NO ❑ �', f I ,l�/ <br /> CHECK N, PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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(3-2-68) 0 0 <br />