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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ' <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' . " <br /> COMPLETE THIS FORM FOR EACH FA VISITE <br /> c'Flroxq <br /> MARK ONLY ❑ I NEW SIT ❑S RENEWAL PERMIT [215 CHANGE OF INFORMATION ❑ 7 PERMANENTL SITE aLI <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE �! •O <br /> I.FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W <br /> FAGUTY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> _Zln C QJCff W <br /> NEAREST CROSS STREET ✓Imwl ❑ PAWMBSs, ❑ STAIE-AmAcy <br /> /7uJ.J oS eom Com PT f�GJ /�v 11OXINUTION 11IDOLAGEIKY ❑ MOVEVAC <br /> CRY NAME ❑ Immmw ❑ cGNIRAMNCI <br /> STATE ZIP CODE SITE PHONE M,WITH AREA CODE <br /> CA Qss3 av9 as <br /> TYPE OF BUSINESS ❑E OISTfl 0R ❑A PROoew ✓Box it INDIAN EPA 10 a <br /> ❑I GASSfATXIN [:]]FARM M-5­OTHER flESERVATION of F W TANK'% Q <br /> TRUST LANDS ❑ ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,F=T) PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> 17e,4f /` Gt X09 e239 `O ! Cr ci 3 — <br /> NIOHTS: NAME(lA5T,FIRBT) PHONE N WITH AREA CODE NIGHTS: NAME RAST,FIRST) PHONE%WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING w STREET ADDRESS ✓ Illoicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME / STATE ZIP CODE PHONE Y,WITH AREA CODE <br /> plG 'Or C/"71e_ G/,I_ 9 5 ic/o.7 <br /> 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> f e P /ice.to Ca - fle T{f <br /> MAIUNG w STREET ADDRESS q ✓ wwW le 11 PARTNERSHIP El STATE-AGENCY <br /> A. ! CORPORATION D LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 11COUNTY-AGENCYCITY NAME STATE ZIP CODE PHONE F,WITH AREA CODE <br /> 9633& 'pew 9 oro <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. ❑ IL ❑ IIL❑ <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 a JURISDICTION F AGENCY K FACILITY ID K %of TANKS al SITE <br /> CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE WITH AREA CODE <br /> /-9 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E% (RATION DATE <br /> C/ <br /> LOCATION CODE CENSUS TRACT F SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> n >_ U YES NO <br /> CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTS BY: <br /> THIS FORM MUST fl$\"CC MPANIED BY AT LEAS )R MORE TANK PERMIT FORM 'B'APPLICATION(S), 1 !S THIS IS A CHANGE OF SITE INFORMATION LY. <br /> /1 DATA PROCESSING COPY <br />