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STATE OF CALIFORNAI WATER RESOURCES CONTRIAROARD OF <br /> 1 , m <br /> RM A: UNDERGROUND STORAGE TANK PROGRAM = " Z <br /> SITE n FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ;/ <br /> f f COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE w <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> n AANEAREST CROSS STREET ✓ IoiMira@ Cl PARTNERSHIP ❑ STATE AGENCY <br /> CJS /v/ _ lT-[� CORPRATION 11LOCALAGENU ❑ FEDERAL AGENCY <br /> /T Z'/ E3 INDIVIOUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE E PHONE#,WITH AREA CODE <br /> 129/)V)*R CA 0 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR */Box A INDIAN EPA ID ft O <br /> ❑ 1 GAS STATION ❑ 3 FARM Rl HO TRUSRESETATOr ❑ �J�4-J�� AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) HONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ,Pellexiau .s6 -063 1 pori Z-3- 2 <br /> NIGHTSNAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS. NAME(LAST FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME %H Lam' - CARE OF ADDRESS INFORMATION <br /> /4 e/R M O 41 eOn <br /> MAILING or STREET A DRESS I/Box toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 5-36) <br /> 3l1 ClCORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> 1 6) LJTP61VIDUAL ❑ COUNTYAGENCY <br /> CITY NAME �- STATE ZIP CODE P NE#,WITH AREA CODE <br /> s �� a <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE DECODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> ec <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ it. <br /> 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# aiiFACILITY ID# # f TANKS a1 SITE <br /> G p <br /> CURRENT LOCAL AGENCY FACILITY ID# APP VED BV NAME HONE#WITH AREA CODE <br /> PERMIT NUMBER <br /> aPERMIT OVAL DATE P IFE%PIRATION DATE <br /> LOCATION E CENSUS SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED �my� <br /> YES NO �-�� �+ O <br /> CHECK# PERMIT AMOUNT SURC ABBE A OUNT 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 ON <br /> FORM A(3-2-88) - <br /> DATA PROCESSING COPY w,� <br />