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STATE OF CALIFORNIAC) WATER RESOURCES CONTROL AIA►RD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM u � l <br /> � a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> C COMPLETE THIS FORM FOR EACH FAC LITY/SITE <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY SITE <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT [716 TEMPORARY SITE CLOSURE O Z <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 10 <br /> FACILITY/SPIE NAME - CARE OF ADDRESS INFORMATION <br /> ADDRESS L NEAREST CROSS STREET ✓Aaw lom x, Cl PARTNERSHIP ❑ STATE-AGEN(Y <br /> 1011 11LOCALAGENGY ❑ FEGEAAL-AGENCY <br /> G ❑ MONIOIIAL ❑ COONTVAGEIJV (A <br /> CITY NAME STATE ZIP CODE SITE PHONE 9,WITH AREA CODE N <br /> CA %s37 0 -QS_70 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUT PROCESSOR Box if INDIAN EPA 10 N #of TANK'. <br /> ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUSTVATION LANDS GI <br /> [7) ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NA (LAST.FIRST) PHONE M WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE it WITH AREA CODE <br /> a <br /> NIGHTS. NAME(I-AST,FIRSTf PHON ITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OFAD RESS INFORMATION <br /> IkI 4/z— U. S srv�o <br /> MAILING or STRE T ADDRESS ✓Box icate ❑ PARTNERSHIP ClSTATE-AGENCY <br /> �'^ ' HPORATION 11LOCAL-AGENCY13FEDERAL-AGENCY <br /> ❑ <br /> V V J[ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STA E ZIP CODE PHONE 4 WITH AREA CODE <br /> III. TANK OWNER INFOAMATfON & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING.,STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE R.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: 1. ❑ it. p, 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 If AGENCY# FACILITY ID# #of TANKS at SITE <br /> 10101113 Ict 1 16 k 10 <br /> CURRENT L C L AGENCY FACILITY ID# APPROVED BY N E /PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE ERMIT EXPIRATION DATE <br /> Z/ <br /> LOCATION CODE CENSU CTM SUPERVISOR-DISTRICTODE BUSINESY PLANFILED <br /> NO ❑ DATE FILET <br /> CHECK NN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BV/:`rin <br /> / <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO R M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION OJRY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY 'ti <br />