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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM Z <br /> S1FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I o <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ERfCHANGE OF INFORMATION ❑ 7 PERMANE OSED SITE F'+ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE ! <br /> F-h. <br /> I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> CJI <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> s os 5 s <br /> ADDRESS //gy�pp ,�/`�I-� �� NEAREST CROSS STREET ✓ 0 PAATNERSNIP 0 STATE MENU <br /> `a !f J O '�I✓' �'�-'� ❑ IN mom ❑ COINTY AGENCY ❑ kVEM4AGENLY <br /> CITY NAMES D G �4 CA STATCODE D a PHONE 9 N,WITH AREA CODE 3 O0 <br /> 11(N <br /> TYPE OF BUSINESS: 2 DISTRIBUiOflE] 4 p M SSOR ✓Box if INDIAN EPA ID 01 TANKN ' <br /> RESERVATION <br /> L31 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS or ❑ - - AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> Oaf,In - a 10 <br /> NIGHTS: NAME(ALASTMFIRST)a PHO N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> s6t , '� <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING wSTREET ADDR S ✓ xto ilWicate El PARTNERSHIP ❑ STATE-AGENCY <br /> OT CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> (J , INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STAT ZIP CODE PHONE p,WITH AREA CODE <br /> �`f IGvt� 5 a Y3 a000 <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILINGw STREETADDRESS ✓Boxmindicale ❑ PARTNERSHIP - ❑ STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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 11. ❑ 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 /> COUNTYIN JURISDICTION M AGENCY k FACILITY ID k If of TANKS at SITE <br /> od <br /> CURRENT OOAL AOENCY FA ILITYJp N APPROVED BY NAME PHONE p WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PER MIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERViOR-DISTRICT CODE BUSINESS PLAN FILED DATEFILED 40 <br /> fl <br /> 1 YES NO OCA <br /> 6 <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M <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 /> FORMA(3-2-88) <br /> �' DATA PROCESSING COPY � <br />