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STATE OF CALIFORNIA-- WATER RESOURCES CONTRODIOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM =" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> LL COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDSITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE q-1 <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ._s 410" <br /> ADDRESS NEAREST CROSS STREET PARNDFN ❑ STATE'ASDO <br /> OIG OL AC11mRwACB <br /> Y <br /> 007'G(Go Sr NOMINAL <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> 's4r,c_ X40� CA <br /> TYPE OF BUSINESS 2 DISfPoD mn 4 PROCESSOR ✓Bud INDIAN EPA ID IT _ t DI TANKY <br /> ❑ I GAS STATION ❑ 3 FARM ❑ RESERVATION or ❑ AT THIS SITE <br /> ❑ 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS. NAME(I-AST.FIRST) PHONE N WITH AREA CODE <br /> NIGHTS. NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHT$'. NAME IIAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> P GS T <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 N.WITH AREA ODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ,.{ ✓Box to indicate 11PARTNERSHIP EISTATE-AGENCY <br /> 6a �� ON El LOCAL-AGENCY❑ COUNTY-AGENCY <br /> ❑ FEDERAL-AGENCY <br /> . "r El INDIVIDUAL <br /> CITY NAME STATE ZIP CODE PHONE M,WITH AREA CODE <br /> C/P <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WNICH ABOVE ADDRBBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 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 /> COUNTY* JURISDICTION R AGENCY S FACILITY ID N Mol TANKS M SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N W ITN AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT It SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI D <br /> Q :2- 3, �1*O 2 5— YES ❑ NO ❑ //-?/ <br /> CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTP BY: <br /> L / <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. ,./C <br /> ORM 2-88 \ , L• v — ��I Q <br />