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r-1111117"V-T-7�—'w'r 11 —11-19 <br /> STATE OF CALIFORNO WATER RESOURCESsir....... <br /> CONTR�BOARD ��.:• .��..,•.y� <br /> FORM `A': s <br /> SITE UNDERGROUND STORAGE TANK PROGRAM V k <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE d <br /> C-0SIFoaN�� <br /> MARK;ONLY 1 NEW PERMIT 3 RENEWAL PERMIT S CHANGE OF INFORMATION <br /> ONE ITEM 2 INTERIM PERMIT ❑ 7 PERMAN NTLY CLOSED SITE <br /> 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE rh <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) V W <br /> FACILITY/SITE NAME <br /> S CARE OF ADDRESS IN�t r PS FORMAT <br /> ADDRESS <br /> n NEAREST CROSS ✓ rloindirale PARTNERSHIPi- 13 <br /> /Y�J.1 C CORPORATION ❑ LOGAL-AGENCY ❑ FEDERAL-AGEN <br /> CITY NAME � CY <br /> S / INQIVIOUAL ❑ C©UNTYAGENCY <br /> i C.! + STATE ZIIPP7r�CODE IT PHO- k,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑(� ❑ CA [ J to©< ?-at) Y3-0513 <br /> �3—V 5 13 <br /> 2 DISTRIBUTOR 4 PROCESSOR ✓Boz it INDIAN EPA ID N <br /> 1 GAS STATION F] 3 FARM �5 OTHER RESERVATION or #of TANK's <br /> TRUST LANDS L-j AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS NAME(LAST,FIRST) <br /> PHONE q WITH AREA CODE <br /> NIGHTS' NAME(LAST,FIRST) PHONE kWITH AREA CODE NIGHTS. NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> fvV1 <br /> ESS INFORMATION <br /> MAILING or STREET ADDRESS ndicale ❑ PARTNERSHIPRATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> UAL ❑ COUNTY-AGENCY <br /> GITY NAME ZIP CODE <br /> PHONE k,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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: 1- IL lil. <br /> THfS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID k f APPRO Y NAME <br /> PHONE k WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT k SUPE ISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 39 Q; , o� YES NO <br /> CHECK N PERMIT AMOUNT SURCHA GE AMOUNT LLLL <br /> ECEIPT kgY. <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(3-2-88J <br /> DATA PROCESSING COPY <br />