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STUNDERGROUND STORAGE TANK PROGRAM ATE OF CALIFORN WATER RESOURCES CONTR OARD <br /> FORM 'A': _ �'m <br /> o z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE cSQF".P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E15 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> Ljj <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) al <br /> FACILITY/SITE NAM .C� FADD ESQ NFOgMA N <br /> ADDRESS NEAREST CROSS STREET ✓Ba.IOIMirak ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> _ ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> C11, ' (^ � f STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> /j CA 5a o <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N #oI TANK'1 <br /> ❑ i GAS STATION ❑ 3 FARM OTHER RESETRUSTTVLANDS or ❑ /�(1 (/-{', AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> 1�12r L, tv a 106 14/L) <br /> MAIL, or STREET A ESS ✓Box to icale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> A O ` / 0 , �j ❑ ORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> o DIVIDUAL ❑ COUNTY AGENCY <br /> CITU AMESTATE/,..�yL ZIP DE PHONE N.WITH AREA CODE <br /> /V O <br /> III. TANK OWNER INFORhi & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box toindicale ❑ 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. ❑ II. 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 N AGENCY M FACILITY ID M If of TANKS at SITE <br /> 3 DOo <br /> CURRENT LOCAL mAPPROVED BY NAME PHONE N WITH AREA CODE <br /> /C�{ <br /> PERMIT NUMBER ROYAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CIEUS RA D SUPERVISOR-�ICT CODE BUSINESS PLAN FILED DATE FILED <br /> a <br /> YES ❑ NO 0 0 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If 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 ONLY. <br /> FORM A(3-2-58) • 6 <br /> DATA PROCESSING COPY <br />