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STATE OF CALIFORNIPIr WATER RESOURCES CONTRCpwSOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> F-1 <br /> ARK ONLY 1 NEW PERMIT F-13 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0 <br /> 16 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITYBITENAME _ CARE OF ADDRESS INFORMATION <br /> Ong boluqLb TFt b' N <br /> ADDRES NEAREST CROSS STREET ✓BOxloiiNxale P ❑ SfATE'AGBo 00 <br /> 1:1CORPmn0N 11LOCAL-AGDKY 11FFDEA4L-AUNCY <br /> 2 0 INDMDUN ❑ WUNIYAGENCY CP <br /> STATE ZIP CODE TE PHONE k,WITH AREA CODE <br /> CITY NAME <br /> CA 952os� (20v) A/&Z-o <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓BOX it INDIAN EPA ID p <br /> ❑ ESERVATION <br /> 1 GAS STATION ❑ El3FARM Q,bOTHETi TRUST LANDS or BB/TANK'e O/ <br /> AT TRIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 2 �(s2-OZS3 <br /> NIGHTS: NAMEW,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LASFFIRST) PHONE%WITH AREA CODE <br /> J A-MC <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NALQaW� C E OF ADDRESS INFORMATION <br /> l hf� NIC <br /> MAILIN 14r ADDRESS ✓Box to indicate PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODG r PHONE N,WITH AREA CODE <br /> C <br /> 195-20'Z5- 20 4& -0253 <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> I <br /> N&AJ&Z CARE OF ADDRESS INFORMATION <br /> G— <br /> MAILING orSTREET ADDRESS ✓Box to indicate ErPARTNERSHIP ❑ STATE-AGENCY <br /> /� 13 CORPORATION Cl LOCAL-AGENCY 13FEDERAL-AGENCY <br /> ? ❑ INDIVIDUAL ❑ COUNT'-AGENCY <br /> CITY N ESTA E ZIP CODE PHONE N.WITH AREA CODE <br /> .J � z-ers3 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVB ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 2.�_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 B SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY B JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> lc 1-0U F OU <br /> CURRENT LOCAL AGE C AGILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> /91 <br /> PERMIT NUMBER PERMIT APP VAL DATE PERMIT EXPIRATION DATE <br /> , <br /> LOCATION CODE CENSUSTRACTI SUPERVISOR-DIS CT CODE BUSINESS PLAN FILED DATE RIE' <br /> IBJ 'l3 Cg <br /> YES [] NO � <br /> CHECKK# PERMIT AMOUNT SURCNA GE AIIAOUMT FEE CODE RECEIPT BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO R M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-SB) <br /> \� DATA PROCESSING COPY �� <br />