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MT'i. '@i'IPSi;. ''::ax: TRF"r°. <br /> STATE OF CALIFORN19 WATER RESOURCES CONTRARIOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM = ' o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' <br /> COMPLETE THIS FORM FOR EACH FA LITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFO R PINION <br /> E Paul t-,;, X-like � N <br /> ADDRESS J NEAREST CROSS STREET ✓ IoiMiwle ❑ PARTNERSHIP ❑ STATE AGENCY <br /> �J 33 Lam}'CORPGRATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ leoimouAL ❑ couenaGENcr <br /> pb <br /> CITU NAME_ STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA S"3 (o r <br /> TYPE OF BUSINESS'. ❑ p DISTRIBUTOR 4 PR OR ✓ROx if INDIAN EPA ID N <br /> ❑ I GASSTATION ❑ 3 FARM OTHER TRUST VATIONo ❑ #o1TANK's <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST PHONE#WITH AREA CODE NI TS NAME(LAST,FIRST PHONE N WITH AREA C/00�E <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMEC CARE OF ADDRESS INFORMATION <br /> / M'!/ l� <br /> MAILING or STREET ADDRESS 10610 <br /> indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> _lzij Y/ Ia ®/CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> L ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME /� STATE ZIP CODE / PHONE N,WITH AREA CODE ` <br /> Z) <br /> A/6,`/'7V <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 ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A,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. 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID At #of TANKS at SITE <br /> MI = = 1616 Oce 10 / <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL GATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DI TRACT CODE BUSINESS PN FILED DILED � I <br /> a YES [] NO 3 <br /> CHECK# 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 /> v DATA PROCESSING COPY <br />