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STATE OF CAL FO RNI10 WATER RESOURCES CONTRAWOARD FORM `A': ��ewr •. _" UNDERGROUND STORAGE TANK PROGRAM s FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE:OF INFORMATION 7 PERMANENTLY CLOSED SITE F J ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑�6 TEMPORARY SITE CIUSUHE / ONO I.FACILITY/SITE INFORMATION&ADDRESS—(MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION -- ADDRESS NEAREST CROSS STREET ✓Bm pMuk ElPARTWCHP CISTATEAGENCY L� 11 MVMA,. 11Gl (o •AGEYCI FlFEDEMI AGENCY Y� ❑ NOMDUA: El LgNfY AGENCY CITY NAME �` / I STATE TIP CODE SITE PHONE N,WITH AREA CODE TYPE OF BUSINESS. ❑2 DISTRIBUTOR ❑1 PROCESSOR ✓Box d INDIAN EPA ID N �^ ❑ TRUST LANDS or U ' Y`� N of TANK'N ❑ 1 GAS STATION y FARM 5 OTHER AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS NAME(LAST,FIRST) PHONE Y WITH AREA CODE DAYS NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS NAME(LAST.FIRST) PHONE N ITH AREA CODE NIGHTS NAME(UST.FIRST) PHONE N WITII AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMA110N S Q!AW MAILING or STREET ADDRESS ✓Dox 10 indicalc ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY — CITY NAME STALE UP CODE PHONE N.WITH AREA CODE I11. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME ��.//�� /^� /��• CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Dox to mJ.calc Cl PARTNEF39HIP ❑ STATE-AGENCY ❑ CORPORATION LI LOCAL-AGENCY ❑ FEOERAL.AGENCY (] INDIVIDUAL Cl COUNIY-AGENCY CITY NAME STATE ZIP CODE PHONE N•WITH AHLA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. _ It. ❑ ILL Ll THIS FORM HAS BEEN COMPLETED UNDER PENAL I Y OF PERJURY,AND TO THE HEST 01-MY KNOWLFOGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED h SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY NJURISDICTION N AGENCY N F CI Y ID M I sn N of TANKS at SITE CURRENT LOC11 AL AO Cl FACILITY IDM JAPPROVEDE PHONE N WITH AREA CODE - PERMIT NUMBER PERMIT APPROVAL DATE FRATION DATELOCATION CODENSTRACT SUPERVISOR-DISTRICT CINESS PUH FILED DATE FI ED YES NO CHI PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `Br APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A 13.2.88) DATA PROCESSING COPY