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STATE OF CALIFORNIAP WATER RESOURCES CONTROOPOARD <br /> W .. <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE L FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F 1LITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ET5 CHANGE OF INFORMATION ❑ 7 PERM, NTLY 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/SITEJyAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Bmbirdose D PA NER5111P D STATE.AGENCY <br /> _ Q L/�v 11 11 <br /> oN ElLOCM AGENCY ❑ FEL£RAL-AGENCY <br /> 6 v ❑ INDMOUAL ❑ COUNWAGENCY <br /> CITY NAME �.� � STATE <br /> CA ZIP CODE SITE PHO# WIT APEA�OD�� <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 4 P ESSOR !✓/Box if INDIA EPA IDN (/j/�'^ M Of TAN <br /> d[K' <br /> 5 <br /> RESERVATION or <br /> 1 GAS STATION E] 3 FARM OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME( ST,FIR I PHONE N WITH AREA CODE DAYS AM ( EA ST,FIRST) �- PHONE N WITH ARCODE <br /> / pias JI' ZGG �2 � `✓/ho <br /> NIGHTS: NAME(LA T,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME( ST.FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate D PARTNERSHIP D STATEAGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CNECKONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. El11. ❑ <br /> F� 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 M JURISDICTION Al AGENCY B FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AD NC CILITY IDN �� APPROVED BY NAME PHONE N WITH AREA CODE <br /> � 2 c / <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> E <br /> [OjDE CENSUSTRACTN SUPERVISO •DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Ly YES ❑ NO ❑ 7�Z PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: G�2� <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 /> v46 <br />