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NATE OF CALIFORNL-w WATER RESOURCESCONTROTSOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> y COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PER ❑ 3RENEWAL PERMIT ❑5 CHANGE OF INFORMATION !tfffl <br /> 'cc I <br /> ONE ITEM ❑2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) tV <br /> CARE OF ADDRESS INFORMATION <br /> FACILITY/SITE NAME ^ <br /> I'�'1ZOG.O( LOC .1 Y100�' Y'^ <br /> ADDRESS NEAREST CROSS STREET ✓3wnroxxV PPAINFRSIIP S1R1E-AGENC! <br /> D OINP rl()N D LOGL#GBII,Y D FEDUK A0130 <br /> I E- V/ 1 �1 U `I� ❑ INDMOIAL ❑ CIXW1Y#CdTICf <br /> STATE ZIP CODE SITE PHONE x,WITH AREA CODE <br /> CITY NAME CA <br /> LOd�I <br /> TYPE OF BUSINESS: ❑ 2 DISTANICS <br /> TRIBUTOR ❑ <PROCESSOR RESBox it INDIAN ERVATION or EPA ID x AIll TTRTANICS <br /> g SITE <br /> ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) <br /> PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to inoicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> I'I MAILING or STREET ADDRESS ✓Box to ind,cete D PARTNERSHIP Cl STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTIONS AGENCY R FACILITY IDB If of TANKS at SITE <br /> 3qEEI �O � a- o O 1 O 1 O I a <br /> CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS"ACT If SUPERVISOR-018TI11CT CODE BUSINE98 PLAN FILED D�ADTE FILED Q 4LY. <br /> t..( ( YES NO .Y1CHECK# PERNR AMOUNTSURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BYAT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S(, UNLESSTHIS ISACHANGEOFSITE INFORMATI <br /> FORMA 3-2-1) <br /> `�'�� DATA PROCESSING COPY �� <br />