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STATE OF CALIFORNIA WATER RESOURCES CONTROOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 P NENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ~ <br /> ❑ 6 TEMPORARY SITE CLOSURE �J <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) w <br /> W <br /> FACILITY/SITE NAME <br /> ADDRESS Go CARE OF ADDRESS INFORMATION <br /> E%BDL/� /z <br /> ,1,,,,, ) NEAREST CROSS STREET i7rsb 0 PANINERy P 0 STATE.AGENCY <br /> w 5 /`�' 4L.fY!" W coerorunav ❑ LBaL-Ac¢Na ❑ ROBUL.ACB�cY <br /> CIN NAME / STATE INGMWAL ❑ [gII'T'AGENCY <br /> [A ZIP CF SITE PHONE N.WITH AREA CODE <br /> 5-7kTYPE OF BUSINESS: ❑ 2 DISTRIBUTOR Ej 44POCESSOR '/BOX it INDIAN EPA D NA <br /> ❑ I GAS STATION ❑3 FARM L_ Y5 OTHER TRUSTYLANDS m ❑ X of TANK1 <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST FIRST) <br /> 14PH9ONE p WI H AREA CODE DAYS: NAME(LA T,FIRST) PHONE p WITH AREA C00 <br /> Ih P�f��D — �� �es8-z/s� <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST, ST) <br /> �1Z PHONE p WITH AREA CODE <br /> u <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME OL CARE OF ADDRESS INFORMATION <br /> Sp,j6 /7 O�� <br /> MAILING or STREET ADDRESS <br /> Box to indicate 11 PARTNERSHIP <br /> P( <br /> 0 , 60 7 2f 0 CORPORATION 0 LOCAL-AGENCY Cl FEDERALGAGENCY <br /> CITY NAME 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> 069STATE ZIP COD n PHONE II,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE CCOOrMMPLETED) � b <br /> NAME CARE OF ADDRESS INFORMATION <br /> S�2 Cl s <br /> MAILING or STREET ADDRESS ✓Box to md'cale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> CITU NAME ElINDIVIDUAL 0 COUNTY-AGENCY <br /> STATE ZIP CODE PHONE k,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOA INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 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 X JURISDICTION At AGENCY N FACILITY ID N N of TANKS at SITE <br /> CURRENT LOCAL AGENCY 5 FACILITY 0 � APPROVED BY NAME / v PHONE N WITH AREA CODE G Z411<5 �o O <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMITEAP ATIONDATE <br /> LCHECKN <br /> CODE CENSUS TRACT N�( SU PERVISOR-OISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> � ;" I �D YES � NO <br /> 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 ONLY. <br /> FORM q(3-2-88) <br /> • DATA PROCESSING COPY <br />