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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A':­ "Jj��, UNDERGROUND STORAGE TANK PROGRAM 4 . <br /> SITE ��-bb--�' FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to <br /> _ ., llb <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��xaa�`" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMAN ED SITE IN& <br /> ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S'U <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACIU SITE NAME CARE OF <br /> NEDDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓9mloiM ❑ PARMIFRSHP ❑ STAi QIND P2 _f�I0WRP0RATIDN 13LOCALAGEIICY ElFEDEAILAGDICY <br /> ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> ®/Ji CA S ZLl6 34 <br /> TYPE OF BUSINESS: p DISTRIBUTOR ❑ 4 CESSOR '/Box if INDIAN EPA ID # <br /> RESERVATION or Not TANK'B <br /> ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ ATTXIS 517E <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGE CY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST FIRST) PHONE p WITH AREA COL <br /> NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> SA <br /> NIGHTS: NAME(LAST,FIRST) - PHONE p WITH AREA CONAME(LAST,FIRST) PHONEp�WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) SS�� <br /> NAME CARE OF tiADDRESS INFORMATION <br /> MA LING orUET AQQQESS - ✓Boy toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑pORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE WITH AREA CODE <br /> C49 <br /> Ill. TANK OWNER 1 FORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STRE TADDRESS I/Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k 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. V 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# JURISDICTION K AGENCY R FACILITY ID N M Of TANKS BI SITE <br /> �b 3 G C d b D 6 <br /> I <br /> RRENT LOCAL AGENCY FACILITY IDzK APPROVED BY NAME PHONE N WITH AREA CODE <br /> , r— <br /> RMIT NUMBERR PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA —i E CENSUSTRACTT NSUPERVIg DISTRICT CODE BUSINESSPLANFILED O �D,AL�TlEE�FOILE <br /> /Z32_j OL// jC� YES [] Ne <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE 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 /> FORLm <br /> -�' DATA PROCESSING COPY ,� <br />