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STATE OF CALIFORNO WATEI ES f e <br /> FORM 'A': UNDERGROUND S UNDERGROUND STORAGE TANK PROGRAM <br /> SITEn FACILITY/SITE, INFORMAL WORK SHEET o <br /> C1 COMPLETE THIS F <br /> FEES PAID <br /> MARK ONLY ❑ 1 NEW PERMIT � 3 RENEWAL PERI <br /> ONE ITEM -4 <br /> 2 INTERIM PERMIT � 4 AMENDED PER NO HRK SHEET RETURNED a <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (ML V <br /> FAcwTv)sIrENAMe CK TURN-AROUND COPIES <br /> FACIUTY/SITENA <br /> MLj <br /> �L Doak S TANKS REG PAID Th <br /> ADDRES <br /> fSSCJ 5ha"J <br /> GIN NAME ADDRESS CHANGE <br /> TYPE OF BUSINESS: ❑�TRIBUTOR � 4PROCESSOR ✓Box InNDIAN EVALUATION INSP <br /> 1 GAS STATION 3 FARM ❑ 5 OTHER RESERVATION or / <br /> TRUST LANDS EVAL INSP MAILED <br /> EMERGENCY CONTACT PERSON(PRIMARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH ARE/ PRECISION TEST RCVD .((/_ <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH ARE/ RELEASE SURCHARGE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS PERMIT TO OPERATE APPROVED <br /> NAME <br /> TRANS FEE <br /> MAILING or STREET ADDRESS <br /> AMEND PERMIT <br /> CITY NAME <br /> RENEW PERMIT <br /> 111. TANK OWNER INFORMATION & ADDRESS— (h <br /> NEW SURCHARGE <br /> NAME /r7 <br /> MAILING or STREET ADDRESS <br /> 3i� iz i�O <br /> CITY NAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE <br /> h THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF F � ` <br /> . — `� —y 1 �O <br /> APPLICANT \(JlT1 <br /> 'S NAME(PRINTED&SIGNATURE) � <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> CURRENT LOCAL AGENCY FACILITY ID# O <br /> PERMIT NUMBER PERMIT APPROVAL DATE k' <br /> LOCATIO q CENSUS TRACT M SUPERVISO -DISTR , <br /> CHECK# yl1 PERMIT AMOUNT SURCHARGE AMOUN <br /> 6/68 UST 23 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERI 1 <br /> ORM A(3-2-88) 40 / <br /> DATA <br /> AIrl n1In0LI i <br />