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v a h a ,anu FORM `A': SITE UNDERGROUND STORAGE TANK PROGRAM FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o �J COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION❑ 7 PERMANENT Y CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) I -AUL -I I Y/SI It: NAME / CARE OF ADDRESS INFORMATION a ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY MAILING or STREET ADDRESS STREET ✓ BOX 101 cale ❑ PARTNERSHIP ❑ STATE AGENCY ADDRESS _ CORPORATION 11LOCAL-AGENCY❑ FEDERAL -AGENCY /'❑ El INDIVIDUAL ❑ COUNTY -AGENCY El LOCAL-AGENCY❑fEDERAt AGENCY CITY NAME ZIP CODE PHONE a, WITH AREA CODE ]NEAREESTCROSS NDINDUALCORPORATI� ❑ CAUNiI�G ZIP CODESITE PHONE #. WITH AREA CODE ' T TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4�THER71RESERVATION ✓ Box it INDIAN EPA ID p ` ❑ 1 GAS STATION ❑ 3 FARM or ❑ # of TANK's TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE a WITH AREA CODE DAYS NAME (LAST. FIRST) PHONE Is WITH AREA CODE NIGHTS. NAME (LAST, FIRST) PHONE a WITH AREA CODE NIGHTS NgME (LAST, FIRST) PHONE It WITH AREA CODE II. PROPERTY OWNER INFORAAATInN JL AnnOCCC — ,aal ler o'It= NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY MAILING or STREET ADDRESS ✓ Box toindicate ❑ PARTNERSHIP ClSTATE-AGENCY❑ CORPORATION 11LOCAL-AGENCY❑ FEDERAL -AGENCY NAME El INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE a, WITH AREA CODE III. TANK OWNER INFORMATION A ADDRFSC — fUl ICT RF rnRAD1 CTcn% NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY /" ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ElCOUNTY-AGENCYCITY NAME STATE ZIP CODE PHONE It. WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLI CHECK ONE (1) BOX INDICATING WHICH ABOVE AI THIS FORM HAS BEEN COMPLETED a ADDRESS LESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ 11. ❑ III. ❑ PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE- IS TRUE AND CORRFCT APPLICANT'S NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # L -71 _-L-L] � I I J Fc -i -I T-) -(--, 7 CURRENT LOCAL AGENCY FACILITY ID N APPROVEq BY NAME 1__)X i q 'PERMIT NUMBER I PERMIT APPROVAL DATE PERMIT EXPIRATION DATE # of TANKS at SITE PHONE # WITH AREA CODE LOCATION CODE CENSUS TRACT SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED DATE FILED •r/a'7 C) ✓ ` / YES ❑ NO ❑ / C) 1� �y / (L CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT # xY• r nra rvnm muo 1 oc At„ %,UMPANItU BT AT LEAST (1) OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. 1 ORM A (3-2-88) 1 DATA PROCESSING COPY