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STATE OF CALIFORNIA WATER RESo <br /> FORM 'A': URCES CONTq� <br /> UND <br /> RGROUND STORAGE <br /> SITE FACILITY SITE , INFORMATION and/orANK PERMIT MM 1 <br /> Z COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> C <br /> MARK ONLY ❑ I NEW PERMIT �Q T �L� <br /> ONE ITEM ❑3 RENEWAL PERMIT 5 CHA,C !NFORMAT.�, /O•V '�` !il <br /> E1 2 INTERIM PERMIT <br /> 4 AMENDED PERMIT 6 TEMFC-e Ry SITE CLOSLF_ <br /> L FACILITY/SITE INFORMATION &ADDRESS — <br /> FACILITY/SITE NAME (MUST BE COMPLETED) PFAM-7NFNr <br /> Cr ADDRESS NFORMA0.!-' /DSf031TF <br /> ADDRESS <br /> NEAREST CROSS STREET ✓Box to iMrz;= - <br /> CITY NAME ❑ CORPORATiOr, V <br /> ❑( <br /> STATE WDMOUAI L <br /> TYPE OF BUSINESSE]2 DISTRIBUTOfl RCA SITE PHI,ZIP CODE <br /> E]4 PROCESSOR ✓Bok AINDIAN EPA ID p A,E-'�Er/CY <br /> t GAS STATION 3 FARM 5 OTHER RESERVATION or ❑ <br /> TRUST(ANDS p oLAcrmcr <br /> EMERGENCY CONTACT PERSON(PRIMARY) AT <br /> DAYS. NAME(LAST,FIRST) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHONE Al WITH AREA CODE DAYS. NAME(LAST.FIRSTI <br /> PHGNEe, <br /> NIGHTS: NAME(LAST.FIRST) PHONE k WITH AREA CODE NIGHTS NAME(LAST.FIRST) <br /> PHONE p yr%� <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF gODRESS INFORMATI CN <br /> MAILING or STREET ADDRESS <br /> ✓Box to RATIO ❑ PggTNERSHIP ❑ STRTE-AGENCY <br /> ❑ <br /> CORPORATION ❑ LDCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CIN NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS <br /> '/Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME ❑ INDIVIDUAL ❑ COUNTYAGENCYSTATE ZIP CODE PHONE q,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. IL E] III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, <br /> AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY ID If If of TANKS at SITE <br /> CUgRENT LOCAL AGENCY FACILITY IO# L <br /> APPgOVED BY NAME PHONE p WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT 0 SUPE�SOR-DISTRICT CODE BUSINESS PLAN FILED <br /> ZZ DATE FIL7/s7/4) <br /> D (( /�77��� <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE YES NO IBJ JS ") O <br /> RECEIPTp BY: -J (C <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEASTJ10R MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-SB) <br /> -`o -� DATA PROCESSING COPY � '� <br />