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STATE OF CALIFORNI9 WATER RESOURCES CONTROPIOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM = � ' <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION j o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `«,.aa�`" <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION En 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S�61 a <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) La <br /> r`0 <br /> FACILITYE NAME nnnnDD- - I a CARE OF ADD^ESS INFORMATION <br /> ADDRESS / N AREST OSS STREET PARTNERSHIP D STATEAGENCV <br /> 'ORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> l ✓ NOI'ORAL ❑ LOCAL AGEENLY <br /> CITY NAME1,1401/ STAT ZIP CODE SITE PHO A.WITH AREA CODE <br /> CA z.t/o Zo TYPE OF OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 OCESSOfl ✓Box ii INDIAN EPA ID a <br /> X of TANK'a <br /> RESERVATION or /��I <br /> ❑ I GAS STATION ❑ 3FARM 5OTHER TRUST LANDS ElCOD6AT THIS SITE OO <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DA NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> ;GG L/b t7S_/ A <br /> NIGHTS'. NAME(IAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHO p WITH AREA CODE <br /> 3/A s4 P .a <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF A^DRESS INFORMATION <br /> TL <br /> MAILING or STREETADDRESS \ ✓Box IO irdicate Cl PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION 11 LOCAL-AGENCY D FEDERALAGENCY <br /> pIND IVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAM STATE ZIPCODE PHONE WITHAREAOODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME/ CARE OF ADDRESS INFORMATION <br /> MAILINGorSTREET ADDRESS ✓Box to indrr,.e D PARTNERSHIP D STATEAGENCY <br /> D CORPORATION D LOCALAGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,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 /> COU INTYY# JURISDICTION R AGENCY# FACILITY ID# If of TANKS at SITE <br /> D � <br /> CURRENT LOCAL AGENCY FACILITY 10# APPROVED BY NAME PHONE M WITH AREA CODE <br /> N I l �Yf <br /> PERMIT NUMBER PERMIT APPROVAL DATjE <br /> P P ITE PIRATION DAYE <br /> 7L <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DATE FILED <br /> YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMO NT FEE CODE RECEIPT# BY: <br /> ' THIS FORM MUST BE ACCOMPANIED BY AT LEAST jjR MORE TANK PERMIT FORM 'B'APPLICATION(S), US THIS IS A CHANGE OF SITE INFORMATION Ow LY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />