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STATE OF CALIFORNI11 WATER RESOURCES CONTRACIARD <br /> A' <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM u �o <br /> SITFFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMAN T SED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00 <br /> IV <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> r <br /> 1 S <br /> ADDRESS (j '/� NEAREST CROSS STREET ✓Em to ieMathi 11 PARTNERSHIP 11 STATE-AGENCY <br /> a (,/� 11NDN DRGAALION ❑ �n,AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME --aa -- STATE ZIP CODE SIJE PHONE H.WITH AREA CODE <br /> Liv' d-,,, CA Pcifj::3 3,10 <br /> TYPE OF BUSINESS: ❑ 2 pl flIBIJFOR ❑ 4 PflOCESSOR ✓Box if INDIAN EPA ID a "" <br /> RESERVATION or � Mol TANK'# <br /> ❑ 1 GASSTATION FARM ❑ 5 OTHER TRUST LANDS ❑ / V v ,vv AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME( ST,FIRST) PHO E#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> r�,ers , W, (ao9 M-33 )6 <br /> NIGHTS: NAME(IAST,FIRSTF PHI N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME F CARE OF ADDRESS INFORMATION <br /> MAILING or STREET AIODRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OFADDRESS INFORMATION <br /> 51)9 <br /> MAILING or STREET DDRESS ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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 KNO WLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION M AGENCY# FACILITY ID IT #of TANKS at SITE <br /> M 9 <br /> CURRENT LOCAL AGENCY FACILITY 10# APPROVED BY NAME PHONE#WITH AREA CODE <br /> teI r ID <br /> PERM I NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOC ION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED NO ❑ DATE FILED <br /> q11:5100 7 <br /> CH CK#I PERMIT AMOUN SURCHARGE AMOUNT 'FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(11 OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY., <br /> FORM A(3-2-88) <br /> �Q,_B 1 0 DATA PROCESSING COPY 0 <br />