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STATE OF CALIFORNIP WATER RESOURCES CONTROWARD / e <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM ' <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION f <br /> ONE ITEM ❑ 7 PERMANENTLY CLOSED SITE I--► <br /> ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) pop <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> NEAREST CROSS STREET ✓Dox"it"o' ❑ PARTNERSHIP ❑ STATE <br /> 'IQ Q ❑ INDIVIDUAORADL ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> CITY ME AGENCY <br /> STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA <br /> TYPE OF USINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Sax d INDIAN EPA ID a <br /> I GAS STATION ❑ 3 FARM ❑ S OTHER RESERVATION <br /> or ❑ #of TANK's <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE pgVS. NAME(LAST,FIRST <br /> 1 PHONE It WITH AREA CODE <br /> LUaCk6 ii)A,;T- s _ y�.I I <br /> NIGHTS: NAME(LAST FIRST) PHONE#WITH AREA CODE NIGHTS. NAME LAST,FIRST <br /> L ��ff ,�..pp ( ) PHONE#WITH AREA CODE <br /> ZcI 5 42—V U I <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NA <br /> CARE OF ADDRESS INFORMATION L <br /> MAILING or STREET ADDRESS <br /> PB rx�ttJJi'd"H ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITU E <br /> El INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE P NE p,WITH AgEA CODE <br /> s C� q �+ )� v a- <br /> III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> eo <br /> MAILING or STREET ADDRESS ✓Bax Io intlicate ❑ PARTNERSHIP <br /> Ll CORPORATION ❑ LOCAL-AGENCY ❑ FEC] STATE AGENCY <br /> DERAL_AGENCY <br /> CI NAME <br /> ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> 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. ❑ 'L ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# <br /> #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID p APPROVED BY NAME <br /> PHONE p WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT pSUPERVISOR-DI TRICT CODE BUSINESS PLAN FILED <br /> 91:) <br /> �' �FDATEE� <br /> �, 3 T YES NO <br /> 1:1 <br /> CNECKk PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> RECEIPTp BY. <br /> / THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `BAPPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> q FORM A(3-2-88) <br /> \1V�1, DATA PROCESSING COPY <br />