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STATE OF CALIFOR* WATER RESOURCES CONT BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAMao Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m l o <br /> nc COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 ERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S <br /> GTi <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) N <br /> N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> veaqeF <br /> ADDRESS3t75 NEAREST CPOSS STRE ✓ ttWb ❑ PAMN5WP ❑ STATEAGDILY <br /> COFPQT���• L/NC�//� INOMDMWALGN ❑ WUN1YAGINCY ❑ �EPAI AGRIGY <br /> CITY NAME STATEDE SITE PHONE N.WITH AREA CODE <br /> CAI <br /> COzas 1 402-9Y3 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOfl 04PROCESMR '/Box B INDIAN EPA ID N- R of TANIPN <br /> ❑ 1 GAS STATION [:] 3 FARM �SBTHER TRUSTRESEY <br /> LANDS or <br /> ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) L /.PHONE N� WITH AREA CSO-DTE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE v( _?- / / <br /> NI S: N ME(LAST.FIRST) PHONE M WITH AREA CODE NIGHTS�NA EIILAST,FIRST) PHONE N WITH AREA CODE <br /> L_rlz� 20? 3, //CC// 11,.x.// <br /> It. PROPERTY OW ER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILINGor STREET ADDRESS ✓ ox to inaicale ❑ PARTNERSHIP Cl STATE-AGENCY <br /> /� / CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> b (7 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> clum.) CTS C4 5-206 - V3-1'7172 <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME AS CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to inaicale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> Cl CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <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 TRU AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY K JURISDICTION N AGENCY N FACILITY ID% K of TANKS at SITE <br /> pof IfRE 10D0k <br /> P <br /> AOEMAL'�C141TY 1 N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACTN SUPERVISOR-DISTRICT CODE BUSINESS;SN FILED NO 1LJED <br /> ,23, F0 2!oPERMIT AMOUNT SURCHARGE 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 /> M A(3-2-SS) (� <br /> / 1f <br /> DATA PROCESSING COPY <br />