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STATE OF CALIFOR WATER RESOURCES CONTIL BOARD <br /> FORM 'A' ;..:;.>e <br /> UNDERGROUND STORAGE TANK PROGRAM = ° �" <br /> SITE J'—� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION "m �� <br /> (_ COMPLETE THIS FORM FOR EACH FACILITY/SITE °+<,.o �> <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT i -ee&ANGE OF INFORMATION <br /> ONE ITEM ❑ PER OSED SITE 16—&❑ 2 INTERIM PERMIT ❑ p AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/ TE NAME CARE OF A RESS INFORMATION Q <br /> ADDRESS, �U <br /> / 2� /r �7�'� NEAREST CROSS STREET ✓CCHMRATIO AINEASEN ❑ STATE AGENCY <br /> l /v •�/�Q ❑ INDHPOMLION COUNTY AGENCY EDEAAL- NCY <br /> CITY NAME ❑ INDIVIDUAL ❑ CDUNN AGENC( <br /> LSTATE ZIP CODE SITE PHO E#WITH REA CODE <br /> CA R�ZyU Zoq 3� 'S�3 <br /> TYPE OF BUSINESS: ❑ 2 DISTR18UTOR ❑��4 PROCESSOR I/Box if INDIAN EPA 10 w <br /> ❑ I GAS STATION ❑ 3 FARM L^7 'OTHER RESERTRUST LANDS o ❑ %>� AT THIS SITE O/ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAMEST,FIRST <br /> PHONE p WITH AREA CODE DAYS: NAM (LAST FIRST) ONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. N E(LAST,FIRST) <br /> ONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> . / �� CARg OF�DRESS INFORMATION <br /> MAILING or STREET D RESS/ //L✓,/Boxmintlicale ❑yARTNERSHIP <br /> ZZ x � `. <br /> El CORPORATION Id LOCAL-AGENCY ❑ FEDERALAGENCY <br /> CITYN ME T ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> 9 D/ STATE ZIP COD PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME <br /> 11INDIVIDUAL ElCOUNTY-AGENCY <br /> STATE ZIP CODE <br /> 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: I. ❑ if. 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 IO# #o1TANKS at SITE <br /> 145 L2 <br /> D 7 D O <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROV D BY NAME <br /> / Vi / Z PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION GATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISO (STRICT CODE BUSINESS PLAN FILED <br /> �� -T DATE FILED <br /> D <br /> CJ YES 0 NO <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODEla <br /> RECEIPT# 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(3-2-88) <br /> DATA PROCESSING COPY 10 1 <br />