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(4•-••qWw,w+4T'rz' :;/l1 dnT14�..r ,-.�.vAp.�....��. rv.•.Fp tzF' <br /> 1 <br /> V ZAP W���Ze <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL'4OARD A <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM "°m <br /> SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� to j <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE "OR <br /> I <br /> MARK ONLY ❑ iNEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 21NTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE02 N <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) G <br /> 00 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> l� r culluhcL.Q ser ; cY, e <br /> ADDRESS .ih NEAREST GROSS e'GNale ❑ PARTNMW 0 STAT-AGENCY <br /> OSS R �7D /9 GUater/o � A�DN oTM �EM.ANRO <br /> CITY NAME (1 / STATCOO <br /> E ZIP CODE � O (;1SITE E N,WITH AREA <br /> TYPE OF BUSINESS. —l/❑J` 2DISTRIBUTOR ❑ 4PROCESSOR ✓Box it INDIAN EPA ID p #/off T�ANICS <br /> .` <br /> RESERVATION or AT THIS SITE <br /> ❑ 1 GAS STATION ❑3 FARM r&14ER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> ao - s <br /> NIGHTS. NAM E(LAST,FIRS HONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAIor STREET ADDRESS ✓ to intlicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 01 a INDIVIDUAL 0 COUNTY-AGENCY <br /> MAIL1 <br /> CIN NAME ^ STATE ZIP CODE PHONE N,WITH AREA CODE <br /> J\' <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I - ✓CO Lo RATIIO 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY � <br /> CITY NAME STATE ZIP CODE PHONE N,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 /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 3� o a o Q 0 <br /> CURRENT LOCAL AGGE1-ENCY FACILITY ID N APPRO ED BY NAME PHONE N WITH AREA CODE <br /> C <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 71//& <br /> LOCATION CODE CENSUS TRACT* SUP VISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3 YES NO <br /> V 1 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOU T FEECODE RECEIPTN 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 /> 11 " FORM A(3-2-BS) <br /> \rSvl/ V DATA PROCESSING COPY A�d % <br />