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STATE OF CALIFORNIlC WATER RESOURCES CONTR BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM o- roe <br /> SITE /FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° o <br /> `/ COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLYEW PERMIT F-] 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION El7 TLY CL SED SITE <br /> ONE ITEM 2 INTERIM PERMIT El4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O O <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) 'A <br /> O <br /> FACILII Y/$laENAME,, ei a QAI�� �E ADDRESS INFORMATION <br /> ADDRESS G J NEAREST CROSS STREET igkale ❑ PARTNERSHIP ❑ STATEAGENGI' <br /> MDUALION ❑ LOCALAGENCY ❑ FEGER4L AGENCY <br /> ❑ INOMORAI ❑ LOCAL AGEENCI <br /> CITY NAME STATE <br /> CA ZIP CODE SITE PHO #,WITH AREA CODE <br /> TYPEOFB ❑USINESS: 2DISTRIBLITOR 4 ESSOR ✓Box it INDIAN EPA ID # S 7,6PESERVATION or X of TANMs <br /> 1 GAS STATION E] 3 FARM 5 OTHER TRUST LANDS ❑ 1 AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LAST,FIRST) PHONE It WITH AREA C_Qi DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ii 2-6q- "0/5 s ev e <br /> NIGHTS: NAME(LA FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> h k tor <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME Q n CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS (/t�p ` ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION D LOCALAGENCY0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME �r CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bax loind,.Ade 0 PARTNERSHIP 0 STATE-AGENCY <br /> Cl CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 'H 0 INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ❑ 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 k AGENCY# FACILITY ID If #of TANKS at SITE <br /> 0 10 1010101 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL GATE PERMIT E%PIRATIO ATE <br /> fm <br /> [CHECK <br /> OCATIO C OE CENSUSTRACTX SUPERVISOR- (STRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Z �O � YES NO ❑ <br /> # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 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 /> FORMA(3-2-88) C/ <br /> • DATA PROCESSING COPY <br />