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� t <br /> STATE OF CAWFOR&, WATER RESOURCES CONTOIL BOAR <br /> Sf�L O'``TIr <br /> FORM `A': D <br /> SITEUNDERGROUND STORAGE TANK PROGRAM <br /> FACILITY/SITE, a " <br /> INFORMATION and/or PERMIT APPLICATION - 1 Al"o <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> =AK ❑ I NEW PERMIT ❑3 RENEWAL PERMIT CHANGE Of INFORMATION <br /> ❑2 INTERIM PERMIT 7 PERMA NTLY CLOSED SITE (� <br /> ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE r� Q <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME // <br /> CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> Q ' + O O NEA ST CROSS STREET ✓Ba Io Mwle ❑ PARTNER%IP ❑ STATE-AGENCY <br /> L/ ❑ COAPOAATIDN ❑ LOCAL-AGENCY ❑ FEpE{IAL�IGEHLy <br /> CITY NAME ❑ INDNIDUAL ❑ COUNTY-AGENCY <br /> STATE SITE AH9NE p,WITH AR� ��/ <br /> TYPE OF BUSINESS: rIrv/� C'A ,��/[J{I(/� <br /> ❑2 DISTRBUTOR ❑4 PIi0CE550R ✓Box if INDIAN EPA ID 4 <br /> ❑ I GAS STATION ❑3 FARM ❑5 OTHER RESERVATION or 0 of TANK's <br /> TRUST LANDS ❑ ,; AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECOI�pARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> ' PHONE N WITH AREA CODE <br /> i <br /> NIGWTS: NAME{LAST,FtAST) PHpNE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHpNE p WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING Or STREET ADDRESS ✓130K to intiicaie ❑ PARTNERSHIP <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGEN <br /> ❑ INDIVIDUAL FEDERAL-AGENCY <br /> CITY NAME Cl❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓BOK to in0icalo ❑ PARTNERSHIP <br /> ENCY <br /> El CORPORATION ElLOCAL-AGENCY ❑ FEDERAL---AGENCY <br /> CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1I BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II. <br /> ❑ III.❑ <br /> THIS FOAM RIAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 6 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION N AGENCY# FACILITY ID N <br /> ® p of TANKS at SITE <br /> 45_�l or d D JJ <br /> CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME / <br /> PHONE N WITH AREA CODE I <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION PATE <br /> LOCATION CODE CENSUS TRACTS SUPERVISOR-DISTRICT CODE - <br /> �D q. BUSINESS PLAN FILED DATE FILED <br /> [f YES ❑ NO ❑ <br /> CHECK N PERMIT AMOUNT SURCHARGE AM UNT FEE CODE <br /> RECEIPT N BY: <br /> C� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM`B'APPLICATION(S), UTHIS IS A CHANGE OF SITE INFORMATION 0f <br /> FORMA(3-2•d8) <br /> ` _cT , DATA PROCESSING COPY N 5S <br />