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*.-... —r <br /> STATE OF CALIFORNIRC�aW G ° <br /> WATER RESOURCES CONTR BOARD -c � '`�•°' �"�. <br /> FORM 'A': UNDERGROUNDT � <br /> S ORAGE TANK PROGRAM <br /> ° <br /> o , Z <br /> .SIT ��FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> I <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT Ti5 CHANGE OF INFORMATION ❑ 7 PERMIAN O/SED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ✓ L <br /> i <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME CAREOFA DRESS INFORMATION <br /> N <br /> ADDRESS L/119 <br /> /� r D , N A STC SS STREET ✓BR Pnati ❑ PARRIER,TIIP Cl STAiEAGBM,Y <br /> ! D EA / ❑ WRGMtIory ❑ LGCALdfiENLY .PfiDIGI' <br /> E, Cl iNOhA7UAL ❑ CIXW A E , �P/ <br /> CITY NAME STATE LV ZIP L� CO SITE PHO E N 1 HAREA CODE C� CA ifr Za' J(�d 317 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ /PROCESSOR ✓Box if INDIAN EPA 10 p <br /> RESERVATION or [ / S of TANK s <br /> ❑ 1 GAS STATION ❑ 3 fAflM 5 OTHER <br /> RESERVATION <br /> LANDS ❑ /`�/q AT THE;SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME( T FIRST) rHONE 4 WITH AREA CODE DAYS, NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> 6 & v 3c�-/ "IDESNIGHTS: NA E .FIRST) PHONE p WITH ANIGHTS: NAME(LAST,FIRST) PA <br /> 0 E F WITH AREA CODE <br /> S SA SA <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAM CAR A F ADDRESS INFORMATION <br /> MAILING or$TRE F,T ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> (f(%(/'I ��L// ❑ CORPORATION ❑ LOCAL-AGENCY EDERAL- ENCY <br /> Cl INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME Goa/, STAT ZIP CODE PHONE k,WITH AREA CODE <br /> 3zYo Zae (_,P-1390 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE <br /> i <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 /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY 7 •� <br /> COUNTY k JURISDICTION M AGENCY R _EACILITY-1D4 N of TANKS at SITE <br /> CURRENT LOCAL / LITY ID a APPROVED BY NAMP,/ PHONE 11 WITH AREA CODE <br /> tul <br /> PERMIT NUMBER Z PERMIT APPROVAL DATE 1-177 <br /> 3PERRMIT EXPIRATION DATE 1 �I <br /> LOCATION CODE CENSUS TRACT If SUPERVISOR-DISTRICr CODE BUSINESS PLAN FILED DATEfILED <br /> 0 v YES NO /3 -f6— <br /> CHECK a PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: <br /> i <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 /> FORM A(3-2-88) <br /> ct(� 5�5�" DATA PROCESSING COPY <br />