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STATE OF CALIFORNIV WATER RESOURCES CONTABOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM VA" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM El INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE D/ <br /> N <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME "STREETIo <br /> s u - s rues Seee <br /> ADDRESS ^ Io lndim 0 PART ASHIP 0 STATE AGENCY <br /> 3CORPORATION ❑ LOCALAGENCY 0 FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYRGENCY <br /> CITY NAME SITE PHONE a.WITH AREA COTE <br /> c�A6�t doR - j <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box ii INDIAN EPA ID At <br /> ❑ 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TgUSRYLANOS ATION or 1:1 <br /> IF HIS SITE AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS'. NAME(LAST.FIRST) PHONE 4 WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING o1 STREET ADDRESS ✓Box to iHaicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NA GAR FAD RESS INFORM <br /> &d <br /> h- p <br /> MAILI Gor STREET ADDRESS ✓ xtoind,c.M 0 PARTNERSHIP STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME 'Sk STATE ZIP CjqpE PHONE N.WITH AREA CODE <br /> ao <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> 'CHECK (1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 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 A JURISDICTION A AGENCY A FACILITY ID k A o1 TANKS at SITE <br /> M = = L2 1011Iv S OQ Q <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVE BY ME PHONE A WITH AREA CODE <br /> tyl�s <br /> PERMIT N MBER PE MI T PPROVA DATE PER�IOV EXPIRATION DE <br /> LOCATION DE CENSUS TRACTM` SUPERVISOR-DISTRICT CODE BUSINE PLA ILED 9 DATE FILED <br /> YES NO <br /> CNEC A PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTa BY- <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIO110), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL <br /> ,/FORMA(3-2-88) <br /> \V1/ 0 DATA PROCESSING COPY 0 <br />