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STATE OF CALIFORNIS WATER RESOURCES CONTRO OARD <br /> : a <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -° 10 <br /> Le�/ <br /> �,1� COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY FL ' NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 P TLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE D� <br /> 1. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME CARE OFIA INFORMATION <br /> ADDRESS' NE EST CROSS FEET ✓m,taiNiute ❑ PARTNEPSRIP ❑ STATE-AGENCY <br /> `�jj A A El El <br /> ❑JBAAGENCY C3FEDEML AGENCY <br /> / 7?J /{'( �C+je.�,� ❑ INDIVIDUAL laCDUNIY-AGENCY <br /> CITY NAME STATE ZI ODE SITE PH E p,WITH AREA CODE <br /> CA Z o�� 6 - 7662— <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> ❑ ❑ RESERVATION or ^�Ap X of TANK'N D Zi. <br /> ❑ I GAS STATION ❑3 FARM 5 OTHER TRUST LANDS ❑ A/\ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME LAST,FIRST) PHONE a WITH AREA CODE DAYS /AME(LAST,FIRST) PH a WITH AREA CODE <br /> QQ1L C2� 36q -i bo Z S/4 �i <br /> NIGHTS: NAM (LASr.FIRST) PHO E a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PH E a WITH AREA CODE <br /> S a 264 V7�- /!3 Z S <br /> 11. PROPERTY OWNER INFORMATION &(ADDRESS - (MUST BE COMPLETED) <br /> N A e0, <br /> ^(/ � li CANRE O�ADDRESS INFORMATION <br /> MAILING or SWT SS Y`Y) ✓box In indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> d.1 / `` ❑ CORPORATION VCA L-AGENCY ❑ FEDERAL-AGENCY <br /> 2ZZ 2w� 6 J ❑ INDIVIDUAL UNT -AGENCY <br /> CITU AME STATE ZIP CODE PHONE .WITH AREA COD <br /> C r7,c 2b, 68-� 9 <br /> 111. 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 ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,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: L ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY X JURISDICTION X AGENCY X FACILITY ID N N of TANKS at SITE <br /> [� oa 66n <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> Al I � L <br /> PERMIT NUMBER PERMIT APPROVAL PTE PER IT PIRATION DATE <br /> LOCATION CODE CENSUS TRACT N GJJ S�UPERVI$ DISTRICT CODE BUSINESS PLAN FILED DATE FILE <br /> �(]�y7 evl/l\ YES NO L <br /> CHEC N PERMIT AMOUNT SURCH RGE AMOUNT FEE CODE RECEIPT N 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(3-2-88) <br /> DATA PROCESSING COPY ` <br />