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w <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> f <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° o <br /> 1 �cl <br /> COMPLETE THIS FORM FOR EACH FA ILITY/SITE °'aroc9�P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ''vERMANENTLY CLOS E h <br /> ONE ITEM ❑ Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE – '4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SRE NAME CARE OF ADDRESS INFORMATION <br /> 104 o Al i4v[,T III Xi cA� <br /> ADDRESS �+ NEAREST CROSS STREET ✓Ib�miWiI 0 PARTNGSPW 0 5TATEAGE0 <br /> 7 J' CA l__I A4lA, /7AZAL-1TD� CDIIPOR4110N ❑ LDGL.AGENC! ❑ FEDEML-AGENC/ <br /> DIE—E 0 CWN1Y-Amicy <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> STbcIGTmN CA '75.2 07 .t o9- h <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑4 PROCESSOR ✓Box BINDIAN EPA ID a <br /> If of TANICs <br /> ❑ 1 GAS STATION ❑ 3 FARM � 5 OTHER TRUST LANDS TION or ❑ O A.C- 000 R&& !4l'3 AT HIS 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 a WITH AREA CODE <br /> 0.A Ivl av9- - ► SurvLe <br /> NIGHTS: NAM (LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> moi)n.e- 5,51 "n- <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Ra ,oL <br /> MAILING or STRE ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> �1 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 6C6r K-rva eA- CA, `is m O 2,91- -19" z(l <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> JCC; <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. gL 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> A PUCANT'S NAME(PRINTED&SIGNATURE) DATE <br /> 4-.?e 89 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> �� = = 1 1 1 101 <br /> CURRENT LOCAL AGENCY FACILITY IDN A� 11 APPROVED BY NAME PHONE N WITH AREA CODE _ <br /> P'1-L–� O <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> Z <br /> FLOCATIONE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> 3�'3 YES NO 0 <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY yy/ <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(3-2-83) ..a <br /> � �„ DATA PROCESSING COPY <br />