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a , • C <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARDn <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Ao <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to <br /> Z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE a <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> L a/L <br /> ADDRESS NEAREST CROSS STREET ✓s ❑ PAATNBSIIP ElSTATE-AGENCY <br /> Ccz Il It NOUN ❑ ODUNTAMCY <br /> CIN NAME STATE ZIP CODE SITE PHONE p,WIT AREA CODE <br /> cu a CA 9sd CGS_ <br /> TYPE OF BUSINESS: ❑ 2 DIST ❑ 4 PROCESSOR ✓Box it INDIAN EPA tD N /� <br /> RESERVATION or <br /> ❑ 1 GAS STATION FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE V <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> r / S _-ju_- <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> -e-IV l Fri uCcs <br /> MAILING or STREET ADDRES/S/�� ) /�C ✓Box to ' ate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> te yC*/ /V. C J� wL-- ❑ C DIVIDUALION Cl LOCAL-AGENCY❑ COUNTY-AGENCY ❑ FEDERALAGENCY <br /> CITY NAME STATE DECODE PHONE N,WITH AREA CODE <br /> 1--rdi C _Y S�Ll o GC K--. <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> .�- <br /> MAILING or STREET ADDRESS Box to - e Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> NDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE 11)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. 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 R AGENCY# FACILITY IDR -2:4R of TANKS at SITE <br /> [R�lLLL4 IW I I oval <br /> CURRENT LOCAL AGENCY FRILI IDN- APPROVED 8Y NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER F l,Q"/•II PERMIT APP110VAL GATE PERMIT EXPIRATION DATE <br /> LOCAT <br /> 9ION <br /> �CCODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> G ( a 3 a 3 YES [] NO ❑ -7 3 <br /> L <br /> K# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: ^� <br /> . , I 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 /> WFORM A(3-2-58) <br /> DATA PROCESSING COPY 1 <br />