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STATE OF CALIFORNIA* WATER RESOURCES CONTROLB ARD 5` "' J"' <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM "" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �'"�aa"�" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENT ITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE L 00 <br /> 3 <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) w <br /> A <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Y i z Lit c— <br /> ADDRESS �f NEAREST CROSS STREET ✓auto Ydaa 11fli PAMIP ❑ STATE-AGENCV <br /> M" / �� Ulc— 11 INU11 �MnCNADUAL ❑11 LOCAL-RICIX 11FEDBUL AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> L p CA 9 �a3L <br /> TYPE OF BUSINESS: ❑ 2 IBUTOfl ❑ 4 Pfi0CES60fl ✓BOaBINDIAN EPA ID x <br /> RESERVATION or e N of TANK'e <br /> ❑ 1 GAS STATION 3 FARM ❑ 5 OTHEfl TRUST LANDS ❑ w�c�— AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(UST,FIRn/S1T) PHONE Ar WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> /Y � r <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE k WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bo indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ PRORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME c/n .y- CARE OF ADDRESS INFORMATION <br /> FF7 L <br /> MAILING or STREET ADDRESS ✓B 0indicate 11 PARTNERSHIP <br /> ❑ STATE-AGENCY <br /> ❑ ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME 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. 11. ❑ 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 N N of TANKS at SITE <br /> ffEl = = I 1 1 &0 lallfl 10101011 <br /> CURRENT LOCAL AGE Y FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBbr PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION <br /> CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE/f,ILED <br /> 7 ( v 323 C� YES E] NO ❑ <br /> / CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: n <br /> r 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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />