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STATE OF CALIFORNIA <br /> WATER RESOURCES CONTRGGOARD '"`'" <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM ° <br /> SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONS �n <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ ) NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION LZ 7 PERMAN LY USED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 6 C. <br /> v. <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) w <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Bour�irm J Pat, All <br /> ADDRESS NEA EST CROSS STREET ✓Bae lmldlute 0 PARTNERSHIP 0 STATE AGENCY <br /> 0 CORPORATION ❑ LOCAL 0 FEDERAL AGENCY <br /> So ✓N 0 INDIVIDUAL 0 COUNT AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> I N CA <br /> TYPE OF eU51 ESS. I❑yp DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ EZ ❑ TRUSRESET LANDS W LION or ❑ AT THIS SITE <br /> 1 GAS STATION 3 FARM 5 OTHER <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> as mnc �, rti 2°9-Z 56 <br /> NIGHTS'. NAME(LASTFIRST) PHONE# ITH AREACODE NIGHTS. NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> u P( �[ <br /> MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP C STATEAGENCY <br /> CNN�/ pL., ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> N C I 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY N E - STATE ZIP CODE PHONE#,WITH AREA CODE , <br /> t C 5 120? r <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAW6 CARE OF ADDRESS INFORMATION <br /> < � Qg <br /> MAILING or STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION 0 LOCALAGENCY ❑ FEDERALAGENCY <br /> 0 INDIVIDUAL 0 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: 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 X AGENCY# FACILITY I #of TANKS at SITE <br /> ��Z= C77q— I ). I �e I S) p I I I V!l— <br /> C T LOCAL AqfNCY FACILITY ID M APPROVED BY NAME PHONE M WITH AREA CODE <br /> cl � <br /> PERMI PROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESSPUN FILED DATE ILED <br /> 77 2-3, 2-3 YES NO Z <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE 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 <br /> i0-u -C2)I <br />