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STATE OF CALIFOFMIA WATER RESOURCES COAPROL BOARD <br /> FORM 'A': W <br /> ate~ <br /> UNDERGROUND STORAGE TANK PROGRAM =�° +�^ <br /> SITE `/FACILITY/SITE, INFORMATION and/or PE MIT APPLICATION z <br /> 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION 7 CLOSED SITE N <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & AD ESS"--(M ST BE OMPLETED) 00 <br /> FACILITY/SITE NAME A <br /> C RE OF ADDRESS INFORMATION <br /> M til CA ij �AC,-TI ve <br /> ADDRESS NEAREST CR SS STREET B eek ❑ PpHINEA3HIP ❑ $iAiEAGENCV <br /> gi.r v TION ❑ LDCALpGFNCY ❑ FEDERAL-AGENCY <br /> ❑ INGMGUAL ❑ Cg1AT/.pGENCY <br /> CITY NAME STATE IF COS 3 3 SITE PHO[E p,WITH AREA CODE <br /> CA 1 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box 11 INDIAN EPA ID # <br /> ❑ 1 GASSTAVON ❑ 3 FARM ❑5 OTHER TRUSTYLANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCYCONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE# EAREA <br /> E <br /> Uc <br /> NIGHTS: NAME(LAST,RRST) �HA NIGHTS. NAME(IAST.FIRST) PHONE N E <br /> II. PROPERTY WNER INF16RMATION & ADDRESS'- (MUST BE COMPLETED) <br /> NAME CARE OFA RE INFOgMATION <br /> Nle g�-Al O/ <br /> , uA,2 c�/Z d 11-TS <br /> MAILING or R ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STA E-AGENCY <br /> �{ 0 , O �� ' ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE 21P ICODEQV 0 PHONE p,WITH AREA CODE <br /> Z LA <br /> C,I��cA d 6 <br /> III. TANK O ER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING or STREET ADDRESS �LOCAL-AGENCY <br /> SHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL AGENCYCITY NAME STATE ZIP CPHONE#.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. ❑ it. EY 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 If AGENCY# FACILITY ID# If of TANKS at SITE <br /> 0o Z / Q 0 6 ® <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE#WITH AREA CODE <br /> M AN760 0 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION GATE <br /> LOCATION CODE CENSUS TRACT If SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Z-4 Fo 32-6 YES [:] NO E] //C <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT 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 ONLY. <br /> �/IORtM[S(3-2-88) <br /> 0 �0 DATA PROCESSING COPY 5 <br />