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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM IA,. <br /> UNDERGROUND STORAGE TANK PROGRAM =" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION d; ' <br /> FC-7 COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ,j Z <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) 10 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ' <br /> Nj('� ans ry <br /> ADDRESS NEAREST CROSS STREET �✓Box�Jww��tltlicale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> 'Jf� ltlfL6RPORAT10N ❑ LCCAL AGENCY ❑ FEDEMLAGENCY T <br /> oV1 �" (CL�IN � ❑ INDNIDl1AL ❑ COUNIYAGENCY �Yw, <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE V <br /> K' CA S3 6 <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID NRESEk of TANKY <br /> ❑ 1 GAS STATION [:] 3 FARM OTHER TRUSTLANDSATION o ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> [NIGHTSYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> Liz® a 4is'.NE <br /> 1LA$T,FIRST) HONE N 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 /> � AC1Flc, RWWONIF, <br /> MAILING or STREET ADDRES io intlicale ❑ PARTNERSHIP EISTATE-AGENCY✓ <br /> od� <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Lo ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> >rry)CI NOAC <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> irle <br /> YYLI/i ()A <br /> S A/ N <br /> MAILING or STREET ADDRESS ✓B o'mtlicale EI PARTNERSHIP ❑ STATE-AGENCY <br /> y1 f I ORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> C/ (� INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NA ESTATE ZIP CODE PHONE N,WITH AREA CODE <br /> w C) CA- <br /> 454 Is Z —�07 <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. ❑ 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 R FACILITY ID N R of TANKS at SITE <br /> I <br /> CURRENT LOCAL AGENCY FACI`I APPROVED BY NAME PHONE N WITH AREA CODE <br /> V <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> A,1114-- <br /> LOCATION CODE CENSUS TRACT N SUPE VISOR-pl IC'[CODE BUSINESS Y S N FILED IN ❑ DATE FILE <br /> 14 fir/ <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPTN <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(8-2-88) <br /> DATA PROCESSING COPY y�/y <br />