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STATE OF CALIFORNIP WATER RESOURCES CONTRIBOARD <br /> a <br /> FORM `A% UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE ,-,r <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATIONPERMANENTLY CLOSED SITE F'+ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00N <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) a) <br /> N <br /> FACILITY TENAMECARE OF ADDRESS INFORMATION <br /> Urr-A Gii ru "--C, V {ems cc dz�� <br /> ADDRESS I ,'may^' NEAREST CROSS ST EET ✓RDxI IoIe ❑ PARTNERSHIP ❑ STATE AGENCY <br /> 1 - 1 ' i �U � ❑ INDIVIDUAL ❑ COUNTYAGENCY El LOCAL AGENCY Cl FEDERAL AGENCY <br /> CITY NAME1 l L y� STATE ZIP ODE a SITEPHONEa,WITH AREA Z his, <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box ii INDIAN EPA ID # #of TANK's <br /> ❑ 1 GAS is [—] S <br /> 3 FARM OTHER RESERVATION Or ❑ AT THIS SITE <br /> TRUST LAND <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. Ni FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ek) 2 DG 1� <br /> NIGHTS: NAME(LAST, RST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRSTI� PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 'M n <br /> MAILING or STREET ADDRESS %/Box to indicate Cl PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ BOUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. Ivr it. ❑ Ill. ❑ <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# JURISDICTION k AGENCY# FACILITY ID# #of TANKS at SITE <br /> ED] = = o0ds om <br /> CURRENT L A A.�O.�-¢–N`\CY FACILI ID APPROVED BY NAME PHONE#WITH AREA CODE <br /> �, 1 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION LFIEFMITAMOUHT <br /> SSUUS TRACT# SUPERVISOR-DISTICTCODE BUSINESS PLAN FILED DATE FILED y <br /> 0 a -6 Vv L-� 10 YES NOEJ (2(,� 11CHECK# 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 OI45S <br /> /FORM A(3-2-88) J <br /> DATA PROCESSING COPY <br />