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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM IA': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE T FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° o <br /> _L COMPLETE THIS FORM FOR EACH FACILITY/SITE `' •aa5' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATIONRMAN FLY CLOSED SITE I"'A <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O <br /> 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE ME CAR��AApES51ORMATION <br /> ,�l lie L ,v`^J`C_ !Sc�e�- <br /> ADDRESS NEAREST CROSS STREET ✓BW IN idiare ❑ PARTNERSHIP ❑ STATEAGENCY <br /> S ❑ CORPCRAE104�Qqk.AGENCY ❑ FEDBRALAGENCY <br /> A" AJ L ❑ INDMOUAI ❑ CAUNWAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA S2 <br /> TYPE OF BUSINESS: EPA ID N <br /> ❑ 2 DISTRIBUTOR 4 PROCESSOR Box if INDIAN❑ Y❑ 5 OTHER RESERVATION or ❑ L/\ N of TANK'e <br /> 1 GAS STATION 3 FARM <br /> TRUST LANDS ^ A7 THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST InRRT) PHONE#WITH AREA CODE DAYS: NAME( ST,FIRST) PHONE N WITH AREA CODE <br /> NIGH I S: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS' .NA^ (LAST,FIRST) PHONE#WITH AREA CODE <br /> _ s ' er X <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATIOp� / <br /> zoo � 1 p< L d NCiR"/ 1 t5 CI' <br /> MAILINGor�REETADDRESS ��/ ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> S .`/[V`r 13 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> fss <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 52- o - 67-lzzl <br /> Z <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME � CARE OF ADDRESS INFORMATION <br /> p N77 <br /> MAILING or STREET ADDRESS -/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE Jr.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. ❑ it. 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* JURISDICTION M AGENCY N FACILITY ID N N of TANKS a1 SITE <br /> O0 11 loO <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> PA <br /> LOCATION CODE CENSUS TRACT N SUPERVISO -DISTRICT CODE BUSINESS PLAN FILED DAI FILED <br /> d Z YES NO 1112- g <br /> CHECK M PERMIT AMOUNT SURCHARGE A OUNT FEE CODE RECEIPT N Y: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM IB'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY '� <br />