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I <br /> STATE OF CALIFORNIA' WATER RESOURCES CONTROL-BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE "'...... <br /> FMARK ONLY F__] 1 NEW PERMIT F-13 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENT Y§ SITE N <br /> ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE SQ A <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) fun <br /> FACILITY/SLTE NAME q <br /> / ) CARE OFADDRE55 INFORMATION <br /> C U / <br /> ADDRESS NEAREST CROSS ST EET ✓Bnr WiMimk PAIRNERSHIP ❑ STATE AGENCY <br /> �` a ❑ CORPORATION ❑ LOCALAGENC/ ❑ FEGEML-AGENLY <br /> �,\��000GGG ❑ INOMDUAL ❑ C0uw AGENCY <br /> CITY NAME STATE ZIPCODE SITE PHONE#,WITH AREA CODE <br /> CA po-mJ6 <br /> TYPE OF BUSIN ❑ p D RIBUTOR F-14 PROCESSOR -/Box if INDIAN EPA ID # #of TANK's iS D <br /> RESERVATION or c✓ <br /> ❑ ABSTATIO <br /> I GN FARM ❑ 5 OTHER TRUST LANDS ✓� AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) i EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS NAME(LAST,FIRST) PH E#WITH AREA CODE <br /> ikeUtr5615 -65, s sG <br /> NIGHTS'. NA (LAST,FIR PHONE#WITH AREA CODE NIGHTS/NAME(LAST,FIRST) PH NE If WITH AREA CODE <br /> SIAF(n, JP A <br /> I. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> I <br /> R INFORMATION <br /> NAM CAR OF ADDRESS <br /> v /✓�a <br /> MAILING or STREET <br /> �ODO/RfISIS ✓Box m intlicate PARTNERSH [IIP [ISTATE-AGENCY <br /> Z� L Cl ION FEDERAL-AGENCY <br /> Ill INDIVIDUAL ❑ COUNT AGENCY <br /> CITY NAME STATE ZIP ODE NEN. ITH AREA CODE <br /> "'01 ` `7S 2 a, UR7C4- 6 �].l <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 5`1AZL ,.GpvR- I, <br /> MAILING or STREET ADDRESS ✓Box to iooicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ If. 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 S SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# At of TANKS BI SITE <br /> 10 1,0 1 -z- I I I I R I I !g 10 1 c <br /> 0 1— <br /> CURRENT LOCAL AGENCY FACILITY ID IF APPROVED BY NA PHONE#WITH AREA CODE <br /> FA) '7 y 24 <br /> j T NUMBER PERMIT APPROVAL DA PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSSU/S TRACT# SUPERVIS R-DISTRICT CODE BUSINESS PLAN FILED r_rAT IUD <br /> �` � YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY. <br /> ass <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 /> x#11#MP DATA PROCESSING COPY <br />