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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A4: <br /> UNDERGROUND STORAGE TANK PROGRAM aaa ae <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENT) ESITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE j 0 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACIUTY7SITE NAMECJV <br /> CAflE OF ADDRESS INFORMATION W <br /> ADDRESS NEAREST CROSS STREET / ✓E14X 0 PMTNEABW $TAIEAGENLY <br /> Lir.V/F d EF r "dim ❑ LOM WANLY ❑ FEDEw AGENCY <br /> ❑ Mlmrxlu 0 COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE 4,WITH AREA CODE <br /> �" c/_0 ti CA 9S CJ(o )0 - p <br /> TYPE OF BUSINESS ❑Z OISTRfXROfl ❑/ ✓Box it INDIAN EPA ID 4 <br /> ❑ I GASSTATXN ❑3 FARM OIHFA TRUSRESE7VLAN05 or ❑ jf _ f of HIS SITE ` <br /> -THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE Y WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE 4 WITH AREA CODE <br /> -51Y/;//T f G- - `7Y d '9?0/ 54r c,4- <br /> NIGHTS NAME(LAST,FIRST) PHONE Y WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CANE Of ADDRESS INFORMATION <br /> - <br /> MMLINGOIL STREET ADDRESS ✓Eloa le md,cale ❑ PARTNERSHIP Cl STATEAGENCY <br /> D nQ ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL (7) COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE <br /> Is;//- Z, (_1-4 1 015-121L <br /> 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAUNG or STREET ADDRESS ✓Box to in0¢ale 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL AGENCY <br /> CI INDIVIDUAL 0 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. ❑ 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 A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION F AGENCYII FACILITY ID B N of TANKS at SITE <br /> = 3 , I i s o 1 o 1 a 1 c <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE IF WITH AREA CODE <br /> \. STOCK c-) i <br /> PERMIT NUMBER PERMITAPPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> CJ d 3 Y 1 ,3 C) 3 1 YES E3 NO 3--& - <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Y BY: <br /> G,3 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO R M 'B'APPLICATION(S), UNLES" 'S IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3.2-88) q �,, <br /> -) -?�-� \V DATA PROCESSING COPY <br />