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STATE OF CALIFORNI/ WATER RESOURCES CONTROL BOARD �r <br /> /e�<"ani <br /> FORM `A': `�' <br /> UNDERGROUND STORAGE TANK PROGRAM = " "o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �"'---"-�" <br /> MARK ONLY t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION NTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE N <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> W <br /> AIV <br /> FA LITY/SITAEE N^AAME ' /^�yy�� CARE OF ADDRESS INFORMATION <br /> till !A Z.N <br /> ppppESS NEAREST CROSS STREET/V M,to imam ❑ PAI[DERBIP ❑ STATEAGENCY <br /> 7G, 6JA <br /> r2 WWOMTON 13LOCAEAGENV ❑ FEDB41-AGBILY <br /> D INDIQUAL ❑ COUNTY AGENCY <br /> CITY,,N^ME STATE ZIP CQDE SITE PM NE A.WITH AREA CODE <br /> -1TDGK-7V^/ CA 615,706 r 4&.151-3YA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Boa N INDIAN EPA ID It <br /> RESERVATION or N of TANK'# <br /> 1 GAS STATION ❑3 FARM ❑5 OTHER TRUST LANDS ❑ 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) PHO# N WITH AREA CODE <br /> 1/ANDEFbL P-01\1 �( 446LS�3�fZ 1 Al1�C. M;Q2✓inJ �r_o9X35! <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHO E#WITH AREA CODE <br /> UAnI AP0/0 20; 9S7-1,T7_0_ VMLC-_POc. MAzvi,i �69fE8- <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Rp <br /> Tit7C. <br /> MAILING or STREET ADDRESS <br /> ✓//Boz to indicate ❑ PARTNERSHIP""" 13STATE-AGENCY�kC00PPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> pto, 50y- Q 11 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY STATE ZIP CODE P ONE WITH AREA CODE <br /> 17D c/G7DJ L?A I `752r)/ <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓N Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> III Cl INDIVIDUAL ❑ 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. ❑ it. X 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 B SIGNATURE) neo Al067PDATE <br /> {�/Wl�EE73L t�7L17L�2PRf6ES �iVG !V1 8� <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> Ih 10 10 23 1 S- oC� O <br /> CURRENT LOCAL AGENCY FA I J)Naco / /1 APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER 'Y'N PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE <br /> OI CENSU SUPERVO -D- CCODE BUSINESS PLAN FILED DATE FILEDS YES <br /> LT6N <br /> NO J <br /> ((4 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> �I THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM W APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATIO LY. <br /> FORM A(3-2-88) <br /> %NW ':;ATA PROCESSING COPY <br />