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STATE OF CALIFORNIA' WATER RESOURCES CONTROL BOARD <br /> FORM A : UNDERGROUND STORAGE TANK PROGRAMo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z <br /> G COMPLETE THIS FORM FOR EACH FACILITY/SITE ""O°°"�'� <br /> to <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED SITE I@V� <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE D 8 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> q 34-fr (pr°t S/j//"e <br /> ADDRESS NEAREST CROSS STREET ✓Bm t,ir#kace ❑ PARTNERSHIP ❑ STATEAGENCI <br /> GDAN <br /> S000 S, 6 IX'//. $S- C.E. Q/XON O IxDIVIDUA`lox O AMCY ❑ R aALAGBwv <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> by CA d0/ <br /> TYPE OF BUSINESS ❑p DISTRIBUTOR ❑ 4PROCESSOR ✓Box if INDIAN EPA ID #of TANKS <br /> ESE <br /> ❑ I GAS STATION ❑3 FARM EVOTHER TRUSTY <br /> ATION LANDS a ElAT THIS SITE / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LRST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST FIRST) PHONE N WITH AREA CODE <br /> S , ca, ral <br /> NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 'Care/ Sl�,re <br /> MAILING or STRVET ADORES ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 11 CORPORATION ❑ LO AL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME n STATE ZIP CODE PHONE p,WITH AREA CODE <br /> Lakgnrr 13 Z07-Fri - 53 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Gs ' <br /> MAILING or STREET ADDRESS ✓Boz toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑' CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <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. ❑ 11. v 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 A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID It It of TANKS at SITE <br /> 3 9 O d <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE <br /> M o 50 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> Lm <br /> LHECK# <br /> E CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 1 3. YES NO 9/00/11 <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)A-MORE TANK PERMIT FORM `B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> 1� <br /> vRM A(3-2-88) / <br /> &"' / cl i�/ DATA PROCESSING COPY t(\\ <br />