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STATE OF CALIFORNim� WATER RESOURCES CONTROARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m 0 1! <br /> COMPLETE THIS FORM FOR EACH AGILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 41LUANEkTLY CLOSED SITE h+ I <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT <br /> 6 TEMPORARY SITE CLOSURESO N) <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> y � <br /> FACILITY/SITE NAME Mvrn2 CARE OF ADDRESS INFORMATION <br /> G f4RMA IZe- <br /> ADDRESS NEARESTCRR SSS STTRRE,EETT� nNUENIP E O PAATNB0 STATEAGDO <br /> T/ 1 6 L-/6-S V�• U rJ V�W�V•' MMMTO 0 IOGLAGENGY 0 FM4-AGM <br /> INDMDU1:1 W <br /> AL IINTY.AGFNCY <br /> CIN NAME STATE ZIP C IEr rj p,SITE PHONE WITH AREA. <br /> CODE <br /> CA <br /> S <br /> 570 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 ESSOR ✓Box if INDIAN EPA ID a <br /> I GASSTATION 3 FARM OTHER RESERVATION or ❑ - AT THIS SITE / <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FOIRST) �� H=NE M W AREA CODE DAYS. NAME it AST.FIRS PHONE k WITH AREA CODE <br /> tv <br /> NIGHTS: NAME(LAST,FIRS PHONE N/0 WITH AREA CODE NIGHTS: NAM SILAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME ^V) %e CARE OF ADDRESS INFORMATION <br /> ��R la M 5 <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE AGENCY <br /> S /1{t//( G 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> / —" "`" L • ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE I C0 �� PH ONES A,WITH AREA CODE <br /> 6A IIII. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME O CARE OF ADDRESS INFORMATION <br /> S G o t/2f d ^1 oro <br /> MAILING or STREET ADDRESS .✓.13ox to indicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> i IM CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> / 0 1 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE � PHONE If,WITH A CODE <br /> S-rOc-Ge-TO JJ ZD 6/-�1 <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. ❑ 111. <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 N JURISDICTION N AGENCY N FACILITY ID If N o1 TANKS at SITE <br /> 39 10b 0 30 U (� 0 <br /> CURRENT LOCAL AGENCY FAC�16ITY IDN APPROVED BY ME PHONE M WITH AREA CODE <br /> 7aa y 11-AleiftilI <br /> PERMIT NUMBER PERMIT APPROVAL DATE _/ PERMIT EXPIIIIATIOM DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> O/ 23 $ 411 <br /> 1 ZlJ YES NO <br /> CHECKk PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT IT BY: <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(3-2-88) <br /> �' DATA PROCESSING COPY <br />