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STATE OF CALIFORNIA WATER RESOURCES CONTROL BIRD <br /> FORM 'A': 1 . <br /> UNDERGROUND STORAGE TANK PROGRAMo <br /> SITE n FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION `° o <br /> A- COMPLETE THIS FORM FOR EACH FA ILITY/SITE O�" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ElXcHANGE OF INFORMATION 7 P ENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE U <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) A <br /> FACILITY/SITE NAME , //L� <br /> Co1 GI„ CARE OF ADDRESS INFORMATION <br /> ADDRESS / ^/��(/�l•('•fll NEAREBT CROSS STREET igvsR ❑ PARTNEASHIP I--] 51ATE-AGENCY <br /> r "✓LLr WRPDR4,IDN El LOCALAGENCY 0 IEOEILLL-AGBJGY <br /> INONIDGu ❑ GBUNrr-AGENCI <br /> CITY NAME /] STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> CA �27� <br /> TYPE OF BUSINESS: n 7/bISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA IDN X of TANKN <br /> �,(�/ RESERVATION or <br /> ❑ 1 STATION �.J3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> GAS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(UST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 4 6 y v U/ <br /> NIGHTS: NAME(LAST,FIR ) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STR!EkA D Ej , I/Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ((}5//((66 66 ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> O/IC O` ❑ INDIVIDUAL � ❑ COUNTY-AGENCY <br /> CITY NAME d STATE ZIP C PHONE N,WITH AREA CODE <br /> Ir <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME 56I A9�_'7- ^ w )IZCARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS / ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMExY / STATE. ZIP C DEE J� PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> II; CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR EOTN 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 R JURISDICTION R AGENCY N FACILITY ID R R of TANKS BI SITE <br /> == 101641iff if 10010 <br /> CURRENT LOCAL AGENC -FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> ' <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR- (STRICT CODE BUSINESS PIAN FILED DATE FILED <br /> 3 3�✓ YES NO ❑ <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT♦ Bl': -V/e� <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 /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br /> I <br /> I <br />