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RECEIVED <br /> STATE OF CALIFORNI wf RSL >�t�ANrR oARD , <br /> FORM 'A': DEPARTMENT <br /> SITE UNDERGROUND STORAGE TANK PROGRAM <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ie 1 0 <br /> EMA.R.K,ONLY ❑ I NEV�ERMIT F]3 RENEWALPERMIT S CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITEEM <br /> 1:12 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION&ADDRESS—(MUST BE COMPLETED) _ <br /> FACILITY/ NAME „ CARE OF ADDRESS INFORMATION <br /> ADDRESS NEARESTCROSSSTREET ✓Nr+tordolt ❑ 1ARINMILP ❑ $IAIFALENCY <br /> 11Clki'(YUTKH 13FON AUP C! 11 FEMPALAGENCY <br /> IFaDfADik Elco,In.ACEna <br /> CfIY NAME /' / STATE ZIP CODE SITE PHONE M•WITH AREA CODE <br /> TYPE OF BUSINESS: p I�SiR 4 Km` S ✓Box if INDIAN EPA D A <br /> ❑I GAS STATION U 3 FARM E]5 OTFER TRUSFIESEESETVLANDS AlfON or ❑ A of TANKI <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERS (PRIMARY) EMERGENCY CONTACT PERSON(SECONDAR ) <br /> DAYS NAME(LAST.FIRST) PHONE I WITH AREA CODE DAYS: NAME(LAST,FIRST) PH NE N ITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE I WITH AREA COOS NIGHTS NAME(LAST,FIRST) f 10NE WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATIO &ADDRESS--(MUST BE CO P TE ) <br /> NAME CARE OF ADDRE INFO ATION <br /> MAILING or STREET ADDRESS ✓Box to irdic ❑ PARTNERSHIP AO STATE-AGENCY <br /> ❑ CORPORA ❑ LOCAL-AGENGY ❑ FEDERAL-AGENCY <br /> ------._ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE u,WITH AREA CODE <br /> III, TANK OWNER INFORMATION &ADDV- MUSTBE COMPLETED) <br /> NAME UCORPOFLATION <br /> DRESS INFORMATION <br /> MAILING or STREET ADDRESS i�ulKato ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ORATION ❑ LOCAL-AGENCY [] FEDERAL-AGENCY <br /> IDUAL ❑ COUNTY-AGENCY <br /> CITYNAMEZIP CODE PHONE n.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRCHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULL NOTIFICATION AND BILLING: I. II. [] HI.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND 1-0 HE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 6 SIO NAT URE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY r JURISDICTION N AGENCY h FACILITY M M of TANKS at SITE <br /> CURRENT LS.CAC AGENCY F C LITY ID E ADD VE O BY NAME <br /> PHONE 1 WITH AREA CODE <br /> PE MITNUMSER PERMIT APPROYAL DATE PER MIT EXPIRATION DAT <br /> LOCIi ON CODE CENSUS TRACT/ 8P R-DISTRICT CODE DUSINESS PLAN FILED DATE FIL D J <br /> \ YES NO <br /> t <br /> CHECK PER rr.COUNT SURCHARGE AMOUNT Fff CODE RECEIPT i BY:7_ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(32.88) \ <br /> DATA PROCESSING COPY <br /> V <br />