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STATE OF CALIFORMalt WATER RESOURCES CONTRbLBOARD <br /> ti �A <br /> FORMA': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE x" <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTI_LgLQLLDSITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Z <br /> Id <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> /aE CARE OF ADDRESS INFORMATIONACNrrAiC . <br /> N <br /> ADDRESS NEAREST CROSS STREET ✓BeRb iNlNle ❑ FAHfNDSHP ❑ STATEAGENCY <br /> WIPDMTDN 0 LOCAL AGENCY ❑ FEllBw.AGENC' <br /> Pmte-r 34. Pa r K 0 INDMOUAL 0 COUNTY AGENCY <br /> CITY NAME STATE IF CODE SITE PHONE N,WITH AREA CODE <br /> S o C, CA 0 ao9 `l5/ -loY60 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR I <br /> E'/Box it <br /> INDIANTION ❑ EPA ID a ROI TANK's <br /> ❑ I GAS STATION ❑ 3 FARM U drATHER TRUST LANDS 'V T L o AT THIS SITE / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Vl nce ,Er4r i ao4)�'5/-G ot5 <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Same <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME • CARE OF ADDRESS INFORMATION <br /> Sayre. QS . S� f � <br /> MAILING rSTREET ADDRESS ✓mix to indicate 0 PARTNERSHIP 1:1 STATE-AGENCY <br /> D 9 LDj CORPORATION 13LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP ODE PHONE R,WITH AREA CODE <br /> <5 cK Ofd cA 15AO1(.101)951 - ce-vDO <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Some- aS er <br /> MAILING or STREET ADDRESS I v -/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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. ❑ It.X 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# FACILITY ID N #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY 10 If APPROVED BV NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE Q <br /> LOCATION CODE CENSUB A SUPERVISOR-DISTR CT CODE BUSINESS lP SN FILED NO ❑ DATE 7/QFIL�(+ <br /> 1 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTp BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORM A(3-2-08) l/\) <br /> DATA PROCESSING COPY +7 <br />