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STATE OF CALIFORNIH WATER RESOURCES CONTRIP BOARD 4 � <br /> � >> m <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM _ o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> �44poq NSP <br /> G+ COMPLETE THIS FORM FOR EACH FACILITY/SITE — <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �) / <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> R I7 Pre�t c /k li <br /> IP El STATE AGENCY <br /> ADDRESS NEAREST CROSS STREET 0 CORP0 11M ON C LDGAb�NCY Cl FEDERAL-AGENCY <br /> Z ❑ INDIVIDUAL ❑ CWNIYAGENGY <br /> CITY NAME OO T/ STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA 95.2 ' 7- 36 -ga7yl <br /> EPA ID N <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ d PROCESSOR ✓Box if INDIAN «of TANK'N <br /> RESERVATION or AT THIS SITE <br /> �1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) <br /> PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> 4 a /1 -3G?-9 <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> kararYi /3x ZO`P - 33 b <br /> I/Box to RATIIO C PARTNERSHIP C STATE-AGENCY <br /> MAILING or STREET ADDRESS <br /> Y�? 00'k 5 El CORPORATION ❑ LOCAL-AGENCY C FEDERAL-AGENCY <br /> ❑ INDIVIDUAL CCOUNTY-AGENCY <br /> CITY NAME STAR I L q ZIP CODE PHONE N,WITH AREA CODE <br /> Z&06' <br /> cd C,4 <br /> Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME , CARE OF ADDRESS INfORMATI ON <br /> v,y�rsr, /ecf i� o , G <br /> MAILING or STREET ADDRESS ✓Box to,M',, to C PARTNERSHIP C STATEAGENCY <br /> ❑ CORPORATION C LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> G RO g C INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME !� STATE ZIP CODE PHONE N.WITH AREA CODE <br /> ('¢ 1152 5 3 <br /> c�o� <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 N JURISDICTION N AGENCY N FACILITY ID M R of TANKS al SITE <br /> \ CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> T. PERMIT NUMBER S PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> (�I <br /> A LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> .AZO %/%6 0 <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> C <br /> Q <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 /> S <br /> FORM A(3-2-BS) • • <br /> �`l <br />