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STATE OF CALIFORNIX WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> i COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION n 7 PERMANENTLY SED CLOSED SITE I"#` <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE T7a1LYf � <br /> v l <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) (m <br /> CO <br /> FACILI SITE NAMEO tCAREGOI�JS IN <br /> FORMATIONI' <br /> ADDRESS NEAREST CROSS <br /> s STREET BwlorrY 11 PARTNERSHIP El STATE AGC <br /> aCs oouaT0OUNElEEoea FEDERAL <br /> ( 0 C orKIMiCOUNTYY-A Na <br /> CITY NAME S ATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> N d tJ CA 535 icN <br /> TYPE OF BUSINESS. 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box i1 INDIAN EPA ID p <br /> ❑ I GAS6TATION [:] 3FARM 5OTHER TRUSTYLANDS or ❑ If of TANK'# <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> usss I 209 S79, <br /> — /5dS USC <br /> NIGHTS: NAME(IAST,FIRST) �+ , PHONE#WITH AREA CODE NIGHTS'. N ME(LAST,FIRST) PHONE#WITH AREA CODE <br /> "zr en�sscr F69— S.-I,f--3365 UPI <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ii u '! <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> p p ORPO [I11RATION LOCAL-AGENCY FEDERAL-AGENCY <br /> 4 Q O�Q 'NDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE INF#,WITH AREA CODE <br /> �(es--fir, <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WINCH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. Igj HE❑ <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# AGENCY# FACILITY IDM If of TANKS BI SITE <br /> 3q 10o 1 / 2 oaoO <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 0 <br /> PERMI NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATEFILED <br /> 2-3 YES NO C� ' <br /> CHECK It PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 10 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 /> FORMA(3-2-88) <br /> `� DATA PROCESSING COPY �,,.,1 <br />