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ccc <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> u <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAMo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONril to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> FMARK ONLY ❑ / NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION �( 7 PERMANENTLY CLOSED SITE N <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) '? <br /> FACILITY/SITE NAM CARE OF ADDRESS INFORMATION C 1 <br /> e o Ga�G Fm>✓ d ka s <br /> ADDRESS ' NEAREST ROSS STREET ✓3p,q itli[ale PApiN%lP 0 STATE- DCT <br /> Z Q/�� 0 CDRPDRAiIDN I�tBCALAGENLY ❑ FEDERAL AGDCY <br /> /V� 0 INWDUN 0 W 1171 AGM(7f <br /> CITY NAME Q STATE ZIP ,7_ 0 SITE PHONE N,WITH AREA CODE <br /> G CA `! `f 20 -333- 6'7Y0 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR J Boz if INDIAN EPA ID N <br /> ESE❑ of TANK's <br /> 1 GAS STATION [:]3 FARM OTHER TRUSTY <br /> LANDS ATION Dr ❑ /Y/ ATTHISSITE I <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LA$T,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> tT 947-0 _ o�-3 �- /J <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NA E(LAST,FIRST) PHONE N WITH AREA CODE <br /> / /2/T X gTo/Z 20?-k&'-S73,5 UN <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> / ��� CARE OF ADDRESS I <br /> C NFORMATIO <br /> ///~/'1 u ar as <br /> MAILING or SIRE ADDRE /� /) ✓Box to in0icale ❑ PARTNERSHIP ClSTATE-AGENCY <br /> j //� !C 0 CORPORATION �IJCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME 0� STATE ZIP QE��� PHONE N,WIT_T33CODE <br /> 6" 7 O <br /> 202­ <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> 'WC 14S <br /> MAILING or STREET ADDRESS ✓Box to intlicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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: 1. ❑ I 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 R JURISDICTION R AGENCY F FACILITY ID R R of TANKS at SITE <br /> Lo Q� 10 10 1 2- 6 116 1 10Od I 1 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> 4o,01 2— <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPER )BOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE <br /> CHECK* PERMIT AMNO SURC /AMOUNT FEE CODE YES ❑RECEIPTNO ❑ �B� <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(3-2-68) <br /> DATA PROCESSING COPY ` 5 <br />