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STATE OF CALIFORNIA WATER RESOURCES CONTROLB AR <br /> oe <br /> O D <br /> FORM `A': i <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITIE" FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - + ;1 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��•oaN`" <br /> MAR ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT �6 CHANGE OF INFORMATION ❑ 7 PERMANE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACT SITE NAMMEE CARE OF DDRESS INFORMATION <br /> 4n.1 <br /> ADDRE 5 NEARESy ROSS STREET ✓ oxlo mjor? ❑ PARTNERSHIP EISTATE-AGENCY <br /> CORPORATION C LOCAL AGENCY C FEDERAL-AGENCY <br /> ❑ INDIVIDUAL C COUNTY'-AGENCY <br /> CITY NAMk--7s STATE ZIP SITE P ONE#,WITH AREA CODE <br /> Sn� �o�-� CA 1�32 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID p #of TANK's /a <br /> ❑ ❑ ❑ TRUSRYLANOS ATINOdr ❑ ,� AT THIS SITE V <br /> I GAS STATION 3 FARM 5 OTHER <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> pAVSvn NppAME(LASTFwST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) E`P NE#WITH AREA CODE <br /> NIGHTS. NAME( ST,FIRST) PHONE 4 WITH AREA CODE NIGHTS- NAME(LAST,FIRST) $FINN E#WITH AREA CODE <br /> +Cl a uh(//� <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 54 <br /> MAILING or STREET ADDRESS ✓Be.to od,e le C PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION C LOCALAGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL C 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 /> VA <br /> MAILING or§THEET ADDRESS ✓Box to indicate C PARTNERSHIP C STATEAGENCY <br /> C CORPORATION ❑ LOCAL-AGENCY C FEDERAL-AGENCY <br /> C INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,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. v it. ❑ 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# AGENCY# FACILITY ID# It of TANKS at SITE <br /> AYE10 10 11 � � b 00 10 <br /> CURRENT O AL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> (C <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHkt5'K# <br /> E CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED - DATE FILED <br /> Z J (p ?� YES ❑ NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTp BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST§R MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.^ <br /> FORMA(3-2-58) �J <br /> DATA PROCESSING COPY <br />