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STATE OF CALIFORNO WATER RESOURCES CONTRPBOARD <br /> FORM `A': W: a <br /> UNDERGROUND STORAGE TANK PROGRAM 'm <br /> SITE "^ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION L0 ; <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C9�/fppN�P'/ <br /> =MARK ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ENTLY CLOSED SITE p-1 <br /> ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) co <br /> co <br /> FACILITY/SITE NAME <br /> } 15"t4A' I� CARE OF ADDRESS INFORMATION <br /> _inADDRESS /' <br /> lolNEA?EEOIS,�EE� Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> –/ f V�I �j C �y� e e ? ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL AGENCY <br /> CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STAIPPDE SI.T�E P,�HgONE NWITH AREA CODTYPE OF BUSINESS LN�s <br /> 022 IBUTOR ❑ q PROCESSOR ✓Box it INDIAN EPA ID N <br /> ❑ 1 GAS STATIONM ❑ 5 OTHER RESERVATION or ❑ N of TANK's <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) TT <br /> PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRS PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FI ST) <br /> PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> Fi iiCARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ^� ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> G ' ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE I ZIP CODE PHONE N,WITH AREA CODE <br /> �' Plus✓ 66 -3. <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP <br /> El STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ElCOUNTY-AGENCYCITY NAME STATE ZIP CODE <br /> 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. ❑ 11. IIJE <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) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION k AGENCY k FAC LITY ID k <br /> k of TANKS aI SITE <br /> DO/ I I I T-1 <br /> 01CURRENT LO NCY FACILITY ID 0 APPROVED BY NAME - <br /> "�- PHONE M WITH AREA CODE <br /> PERMIT NUMBER PPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CQDE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> � - �� DATE FILED <br /> �— YES ❑ NO ❑ /U—L��l ' <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> RECEIPT N <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 /> DAT.", PROCESSING COPY <br />