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9t'auu�„ j�F <br /> STATE OF CALIFORNIA- WATER RESOURCES CONTROL-'AOARD <br /> FORM NA': <br /> UNDERGROUND STORAGE TANK PROGRAM ® �o <br /> SITE L FACILITY/SITE, INFORMATION and/or P RMIT APPLICATION <br /> C'a4 aO RNJ <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ftT 5 CHANGE OF INFORMATION ❑ 7 NTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAA�—• CARE OF ADDRESS INFORMATION <br /> [ 0 gA-N&14 El <br /> ADDRESS , L q / ^A q =NEAREST STREET 0 �PATON 0 LGCLAGEN.YIx 0 ��_AGENCY <br /> 3S I 1 Wt L�fT,v/T✓ ❑ POMDUAL ❑ UNTYweNla <br /> CITY NAME STATE ZIP CODE SITE PHONE x,WITH AREA CO E <br /> -T,Z CA X143 <br /> */Box if INDIAN EPA ID x <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 5 PROCESSOR RESERVATION or ❑ N of TANK'S <br /> ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DA)lS NAME(LAST,FIRST) PHONE p WITp A_RE�CO�f E DAYS. NAME(LAST.FIRST) PHONE p WITH AREA CODE <br /> [ uc64 TMI�Af d 5' 3 <br /> NIGHTS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to iMkale 0 PARTNERSHIP 0 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 /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to ioftale 0 PARTNERSHIP 0 STATE AGENCY <br /> 11 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADGREES SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 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 /> COUNTY N JURISDICTION N AGENCY N FACILITY IDN N of TANKS N SITE <br /> / I 1 1010 <br /> CURRENT LOCAL ADEN Y FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> .<5 03S <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE I CENSUS TRACT p SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED p <br /> 1_1 Z 3�"3 2 YES 0 NO —�a <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT SY: <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 ONLYs <br /> FORM A(3-2-88) <br /> 1 i �/ <br />