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STATE OF CALIFORN& WATER RESOURCES CONTRZT[BOARD <br />FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br />SITE % FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br />V( / COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />�OF <br />a'. Y <br />ft° z <br />C44.ip.RK+P <br />PERMIT <br />3 RENEWAL <br />T CHANGE OF <br />IMARK ONLY 117, NEW V ONE EM 2 INTERIM PERMIT❑ -1 4 AMENDED PERMIT 'TEMPORARY SITEE CLOSUREINFORMATION ❑ 7 PER <br />1 <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />FACILITY/SITE NAME ° <br />+ <br />CARE O ADDRESS INFORMATION <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />MAILING or STREET ADDRESS <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />ADDRESS <br />D11 <br />N RST CR S STRE - <br />✓ to indicate <br />❑ PARTNERSHIP ❑ STATE -AGENCY <br />ElFEDERAL-AGENCY <br />i <br />DD Gip <br />❑ NDIVDUALIDN <br />❑ CO NTYAGENCY <br />CITY NAME I <br />P�E/R�MIIT�AP(PRrDA7 <br />STATE <br />ZI CODE -SITE PH NE #, WITH AREA CODE <br />,O/D <br />CA <br />TYPE OF BUSINESS: 2 DISTRIBUTOR4 <br />❑ PROCESSOR <br />✓ Box if INDIAN <br />EPA ID # <br />CENSUS TRACT N <br />At of TANK's <br />❑ i GAS STATION [:]3 FARM <br />OTHER <br />RESERVATION or <br />TRUST LANDS ❑ <br />� ) <br />/�/ <br />AT THIS SITE <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYS: NAM (LAST, FIRST) <br />�..- PHONE #/WITH AREACODEDRAYS: <br />V b (JG+t! <br />NAME (LAST, FIRST) <br />3 <br />Py # WITH AREA CODE <br />!C 4 <br />NIGHTS: NAME (LAST, FI ST) <br />PHONE # WITH AREA CODE <br />NICyWT NAME (LAST, FIRST) <br />PJ,i # WITH AREA CODE <br />. S <br />S <br />(J <br />tl, <br />II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAI31 <br />LING or STREET ADDRESS <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />MAILING or STREET ADDRESS <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />CITY NAME <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE It, WITH AREA CODE <br />III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />NqY6A � _ Yi� <br />CARE OF ADDRESS INFORMATION <br />MAI31 <br />LING or STREET ADDRESS <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br /># of TANKS at SITE <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />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: I. 50, if. ❑ III. ❑ <br />THIS I -'ORM 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 />I nCAI erFNCV IIAF nNLV <br />COUNTY # <br />JURISDICTION # <br />AGENCY # <br />FACILITY ID # <br /># of TANKS at SITE <br />l <br />EIF6 <br />10 /01 olo <br />CURRENT LOCAL AGENCY FA ITY IDN <br />APPROVED BY N �.E // PHONE # WITH AREA CODE <br />DD Gip <br />PERMIT NUMBER <br />P�E/R�MIIT�AP(PRrDA7 <br />PERMIT XPIRATION DATE <br />LOCATION CODE <br />CENSUS TRACT N <br />S PERVISOR-DISTRICT CODE <br />BUSINESS PLAN FILED <br />DAITY ED <br />iq <br />L7.005 <br />YES NO <br />CHECK # <br />PERMIT AMOUNT <br />CHARGE AMOUNT7�ODE <br />RECEIPT N <br />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 />FORMA (3-2-88) <br />10, DATA PROCESSING COPY 0 S7 <br />