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STATE OF CALIFORNIA WATER RESOURCES CONTRAIDARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM o <br /> S [ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE "°." <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY OSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME 1 CARE OF ADDRESS INFORMATION <br /> 44 <br /> �✓ SSJ <br /> ADDRESS NE TC OSS STREET ✓ brOkare D PARTNERSHIP D STATE AGENCY <br /> CORPORATION D LOCAL AGENCY D FEDERAL AGENCY <br /> ❑ INDIVIDUAL D COUNTYAGENCY <br /> CITY NAME. STATE ZIP CODE S TE PHONE P.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: El 2 DISTRIBUTOR ❑ 4 P 13011 ✓Box ii INDIAN EPA ID N N al TANK's <br /> ❑ I GAS STATION ❑ 3 FARM THER TRUSTYLANDS Dr ❑ ✓ — AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST.FIRST) HONE a WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> P <br /> NIGHTS: NAM ST.FIRST) PHONE If WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box W,Nd,cate Cl PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> Cl INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Ban to,r,dc,t. D PARTNERSHIP D STATEAGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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: 1. ❑ II. ❑ 111. ❑ <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 N JURISDICTION R AGENCY 8 FACILITY ID M N of TANKS BI SITE <br /> 39 = = 101oll 4? 13Od f <br /> CURRENT LOC L AGENCY FACILITY ID N APPROVED BY NAME PHONE 4 WITH AREA CODE <br /> a <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODEBUSINESS PLAN FILED DATE FILED <br /> !/ O✓11C 3 YES NO <br /> CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> I� 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 0 <br />