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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM e <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> Z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE I'+ <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE W <br /> O <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) -4 <br /> FACILITY/SITE NAME - CARE qF ADDRESS INFORMATION <br /> e c ON (/I vVl J'�16 <br /> ADDRESS �{q NEAREST CROSS <br /> S ✓ bnarAe D RB11 <br /> PARTN1P D STATE-MENCY <br /> CFn ta� /l �� OI STREET COWpRMYi ❑ LOGL-AGENCY ElFEDERAL AGE10 <br /> Iwillum D OWMAGENCV <br /> CITY NAME OA STATCA ZIP COOE� $I EI AREA CODE <br /> TYPE OF BUSINESS: F-12 DISTRIBUTOR �/PROCESSOR ✓BOX if INDIAN EPA ID p YS <br /> ❑ I CJS STATION ❑3 FARM OTHER TRUSTYLAND$ATION or ❑ N of TANSY <br /> AT TRIS 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 /> Zoq_36?-&7_5' UKN <br /> NIGHTS, N ME(LAST,FIRST)/C PHONE N WITH AREA ODE NI� E(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION &AADD S V— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> R <br /> MAILING or STREET ADDRESS -/Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION Cl LOCAL-AGENCY D FEDERALAGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONEM.WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS (MUST BE COMPLETED) <br /> NAME. -� �� CARE OF ADDRESS INFORMATION <br /> NAME. <br /> E � 0 <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION Cl LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A.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 II. ❑ 111.E:]71 <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 M AGENCY R FACILITY ID N M of TANKS at SITE <br /> 3� 00206 Od <br /> CURRENT LO AL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> F �� aZ <br /> PERMIT NUMBER PERMIT APPROVALDDATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT If SUPERVISOR- ISTIIICT CODE BUSINESS PLAN FILED DATEF E13 �y <br /> 2�,R0 YES NO �I //W <br /> CHECK If PERMIT AMOUNT SURCHARGE AMOUNT FEEOODE RECEIPT• 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 /> FORMA 13-2-88) <br /> -moi DATA PROCESSING COPY ...J <br />