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ALIF©RI gE�' � <br /> STATE 4F C WATER RESOURCES CONTR BOARD w� • �a <br /> FORM A': � ` r no <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EAC ACILITYISITE Cq S+FOR � <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF 6NFORMATiON 0 7 PERMAN N LY CLOSED SITE <br /> ONE ITEM E] 2 INTERIM PERMIT A AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Sllel'/(j)n <br /> GENCY <br /> ADDRESS <br /> =NEAREST5 EETJ111_1 DCAL-A EN ❑ STATOE A-AGE� J I�VIDUAL N ❑ CWNTY-AGEN ❑ FEDENAL-AGENCI❑ INDIVIDUAL ❑ CAUNiY-AGENCY <br /> CITY NAMESTATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> S-Irim- CA <br /> TYPE OF B NESS: ® 2 DISTRIBUTOR d PROCESSOR ✓Box it INDIAN EPA ID # k of TANK'S <br /> 5 OTHER RESERVATION or F-1 <br /> AT THIS SITE <br /> GAS STATION E13 FARM E] TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS- NAME(LAST.FIRST) PHONE,#WITH AREA CODE DAYS OAME(LAY,FIR T) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRSTf PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIR T) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> _w 0fGC <br /> MAILING or STREET ADDRESS +�Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> FJ► ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP COD% PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME iil_�'" '"" CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ,KJ +/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> SNDIVIDUALION ❑❑ C043NTY AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME -�//rJJ STATE ZIP�C+ODE IJ/f PPHHO`NNE#,WITH AREA <br /> CODE <br /> 1 <br /> IV. LEGAL NOTIFICATION AND BILLING {ADDRESS LV i J <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# k of TANKS 1111 SITE <br /> 5M <br /> d � LO b 10 12+ <br /> CURRENT LOCAL AGENCY F CILITY ID# / APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 7� YES NO <br /> CHECK# ( PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> ��fJ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORM A(3-2-88) <br /> rI �f <br />