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STATE OF CALIFORNIWATER RESOURCES CONTRO14OARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE /� FAC LITY/SITE, INFORMATION and/or PERMIT APPLICATION ° 10 <br /> /(;. COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY IV 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMA EO SITE r <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE D N <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) N <br /> FA /SITE NAME CARE OF DDRESS INFORMATION <br /> R. &AA <br /> ADD REss � ) N779TC SS ST EEET.TT. ✓fttrixp ❑ PMTNDSHIP D STATE AGENCY <br /> `.!'�� N'N+' [/L(/'Ci 0 COWOPATICM ❑ LOCAL AGENCY <br /> ❑ FEORUL ENGY <br /> INDADIIAL 11 COUNTY <br /> CITY NA STATE ZIpDE ' SITE PHOVE a,WITH AREA CODE <br /> CA <br /> TYPE of BUSINE55, ❑2 DISTRIBUTOR r❑//PROCESSOR ✓Box if INDIAN EPA ID a <br /> ❑ ❑ LJ TRUSTVLANDS ATION or ❑ t✓ AT THIS K's�� <br /> 1 GAS STATION 3 FARM 5 OTHEfl AT THIS SI <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> YS: AME(LAST,FIRST) PHONE a WITH AREA CODE DAYS. NA E(LAST,FIRST) PH E a WITH AREA CODE <br /> Q� 337 16 SIA <br /> NIGHTS: NAME(LAST,FIRS ) PHONE a WITH AREA CODE NIGHTSNAME(VAST,FIRST) H E a WITH AREA CODE <br /> u Z-Z3 A <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME SA CARE OF ADDRESS INFORMATION <br /> � <br /> MAILING or STREET ADDRESS -/Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCYFEDERAL-AGENCY <br /> ❑ INDIVIDUAL El COUNTY-AGENCY Lx/ <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CAR d; D;r SINFORMATION <br /> MAILINGor STREET ADDRESS ✓Box to,ftcate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> �y '] ❑ CORPORATION ❑ LOGAL-AGENCY DERAL- ENCY <br /> �(J r j Ci ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE DECODE _ PHONE a,WI H 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 a JURISDICTION R AGENCY N FACILITY ID If If of TANKS at SITE <br /> o o I c v (! I o 0 lo <br /> CURRENT LOAL AGENCY AGILITY IO a APPROVE BY NAM � PHONE a WITH AREA CODE <br /> PERMIT NUMBER Z PERMIT APPRROOV DA /PERMIT EXPIRATION DATE <br /> L <br /> LLOCFArDE CENSUSTRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED �•O(�L6C114 YES NO F/ L/PERMR AMOUNT SURCHARGEIAMOUNT FEE CODE RECEIPT BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONl;__� <br /> FORM A(3-2-81!1) <br /> yftw DATA PROCESSING COPY �'1 <br />