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STATE OF CALIFORNI10 WATER RESOURCES CONTRAOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> r� <br /> C, COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 2Tl NEWPERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) c o <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS _ NEAREST CROSS STREET ✓B ¢ale ❑ PARTNERSHIP ❑ STATE AGENCY2 GG �'J, ) CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY 00 <br /> Ll 6 //;/✓ ❑ INDIVIDUAL ❑ COUNTY-AGENCY (7) <br /> CITY NAME10 • � STATE ZIP CODE SITE PHONE#,WITH AREA CODE ry <br /> TYPEOF (NESS: F-] 2 DISTRIBUTOR F-] 4 PROCESSOR ✓BO%iI INDIAN EPA 0 a <br /> 1 GAS STATION 3 FRAM 5 OTHER RESERVATION or #of TANK'# <br /> ❑ ❑ TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS E(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> / y a3� Citi rs 7- <br /> NAM LA FIRST) - PIHpNE k WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PH,311E#WITH AREA CODE <br /> r< s v <br /> II. PROPERTY OWNER INFO MATION & AD RESS — (MUST BE COMPLETED) <br /> NAME CC CARE OF ADDRESS INFORMATION <br /> MAILING or STREET� Z <br /> a /a-i ✓Bax to intlicale ❑ PARTNERSHIP 11 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> *45 <br /> MAILING or STREET ADDRESS ✓Box to iLdicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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. I. ❑ 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# JURISDICTION# AGENCYIN FACILITY ID At Al of TANKS at SITE <br /> CURRENT LD�Alj AGENCY FACILITY ID M APPROVED BY LVn PHONE N WITH AREA CODE <br /> PERMIT NUMBER✓�/C�f � PERMIT APPROV/,i DATE P RMIT EXPIRAC/TTIION DATE <br /> LCHECK# <br /> N CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE <br /> �- YES NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-RR) <br /> DATA PROCESSING COPY <br />