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STATE OF CALIFORA WATER RESOURCES CONTR BOARD <br /> f <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM l 'moo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Ido <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P NTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O ­4 <br /> 1-3 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) -4 <br /> F+ <br /> FACILITY/SITE NAMECARE OF ADDRESS INFORMATION <br /> AL i C2F�T� J-r�t G <br /> ADDRESS 13 I G - 1 NEAREST CROSS STREET ✓ IG 1 ❑ PARTNERSHIP ClSTATEAGENCY <br /> p L 1 /�A( 11 NORPORAIION El LONNTY A GE Y ❑ FEDERAL AGENCY <br /> AGE <br /> CITY NAME STATE ZIP CDOE SITE PHONE 4 WITH AREA CODE <br /> b% CA 9 S <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 4 OCESSOR ✓Box It INDIAN EPA ID a X of TANK'1 <br /> RESERVATION or ❑ AT THIS SITE <br /> ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS it <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE X WI H AREA COD DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> ( k Zv��/�(-3/S ��T-/ M (^ Za <br /> NIGHTS: NAME(LAST,FIRS1 PHONE k WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Dl v) k fl <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME at4v �N(- CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS fix to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /( El CORPORATION 13LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> IF 6 ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITU NAME �IE O STATE A _ ZIP Cg5_"/ PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME ^ - �� CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS Box b intlicale ❑ PARTNERSHIP Cl STATE AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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: 1. ❑ If. III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE 7-71 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY X JURISDICTION Al AGENCY k FACILITY ID X X of TANKS at SITE <br /> [3al0 () I / I a0 610o / <br /> CURRENT LOCAL AGENCY FACILITY ID <br /> a APPROVED BY NAME PHONE X WITH AREA CODE <br /> 1,�.. SIS 1 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRA N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ❑ DATE FILED <br /> n4 a(j YES NO r7 <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT <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 ONL . <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY � / <br />