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t ,, .,..... -.,.. ... .M .,. Y0`111Pd +I.nrnyRT>.r'r..• + ,.-7-.•-1;""�.,+.:-mw--4--w...—,-..: 1 STATE OF CALIFORNI6 WATER RESOURCES CONTRBO D �P➢ �/� /'" �. ''. FORM 'A': UNDERGROUND STORAGE TANK PR GR _ mo SITE FACILITY/SITE, INFORMATION and/or PERMIT APP ICATION I COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 ERMANE CL ED$ITE ONE ITEM EJ Z INTERIM PERMIT N AMENDED PERMIT ID 6 TEMPORARY SITE CLOSURE /Vl L FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION C �x ADDRESS - NEAREST CROSS STREET ✓ bibrle ❑ PARISSP ❑ SIAIEASDKY 0 6 1 3 1 ❑ INGVMTIWJk UYAL4680 ❑ FE k-AGDILY CITY NAME STATE ZIP ODE SI E PHONE N,WITHAREA L CA CODE 53 /� 95 TYPE OF BUSINESS: L_j 2 DIST VISOR Lj A R SSOp I ✓Box N INDIAN EPA ID N + � I GASSTATioN E]3FARM OTHER RESERVATION w ❑ N � a FOITANKY TRUST LANDS ✓� Fes^" AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE AYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE MFIRST),FIRST) \ PHONE N WITH AREA COD NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE II. NER INFORMATION & DRES - (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION DRESS ✓Box toinGicele ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION & A DRESS - (MUST COMPLETED) NAME CA E OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to inbicele ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATIO AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If AGENCY N FACILITY ID R It o/TANKS H SITE CUflflE1LT,A0_ApE FOACILITY IDN APPROVED BY NAME ANT PHONE N WITH AREA CODE JO a F/G PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN OED NO ❑ DATE FILED CHECK# PERMIT AMOUNT SURCHA GE AMO NT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(I)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA F S I R 0 Y. FORM A(3.2-68) ;'\ DATA PROCESSING COPY y,�