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OF T <br /> .> STATE OF CALIFORNOO WATER RESOURCES CONTRRRR%OARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �Q <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> ,-� COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> I <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE V 00 <br /> 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> Cy"1 <br /> FACILITY SITE NAME CARE OF ADDRESS INFORMATION <br /> i v L R �+ o� �,J� I2A i ch Pn mc,-_ <br /> ADDRESS 1 NEARE T CROSS STRFET ✓Boz to indicate ❑ WNERSHIP ❑ STATE-AGENCY <br /> /1 5 e.(',y-11 � � ❑ CORPORATION O LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> lVJ TZJ C r �l-(�ch ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE <br /> L-0a CA q5-:)140 aa9333 � v co <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Box it INDIAN EPA ID# <br /> ❑ ❑ TRUST LANDS ATION�t ❑ #of HIS SITE 1 GAS STATION 3 FARM THER AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST)�j. PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,+tRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME I CARE OF ADDRE FORMZION <br /> Lai f ( r� <br /> MAILING STREET A DRES ✓Box to indicate LJPARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION __Z]-tOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME �CJSTATk., ZIP=DE � PHONE#,WITH AREA CODE <br /> _qd 3l <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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: I. ❑ II. 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 /> FPERMITNUMSER <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> i <br /> 10101A11 <br /> kdq1000 <br /> AAGGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> V�Z� PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUST�TN � SUPERVISOR-DISTRICT�ODE BUSINESSYP S NFILED NO D ITE FIL D11-1 <br /> PERMIT AMOUNT SURCHARGE <br /> SURCHARGE AM,_OILUN((``T 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 /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />