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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM ' <br /> A,: UNDERGROUND STORAGE TANK PROGRAM A, <br /> �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <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 /> GNE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE D J <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CAGE OF ADDRESS INFORMATION <br /> T o S UPNSGN <br /> ADDRESS NEAR ST CROSS STREET bMUV ❑ PARTNERSHIP ❑ STATEAGENLY <br /> //ss/^�/�A.� COWOIUTION ❑ LOX AGENCY ❑ FEDERAEAGENCY <br /> ja5- O�Q IIAA/"/�-/ IIONIW/l ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP ODE SITE PHONE a.WITH AREA CODE <br /> -ac -b-i CA 5206 120?-17W-975-1 <br /> TYPE OF BUSINESS' ❑ 2 DISTRIBUTOR ' <br /> PROCESSOR I/Box if INDIAN EPA ID a R of TANK s e-� <br /> ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUSTYATION LANDS of ❑ AT THIS SITE ✓C <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> rE�NsoA, 20 - sl e 20 9s/ <br /> NIG S'. NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIR ) PHONE A WITH AREA CODE <br /> S1rrx, &42dI -y73-Fry6o Gf <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> uS <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> O CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> N � dCF7G� —• <br /> MAILING m STREET A KESS ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> (y CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> �lpd�� 917Y ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME BCA _11P CODE PHEW=TJAREA 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. ❑ 111. <br /> FEe <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 S JURISDICTION M AGENCY R FACILITY ID R M of TANKS at SITE ` <br /> O 10 1 e�El <br /> CURRENT LOCAL AGENCY FACILITY ID M J APPROVED BY NAME PHONE a WITH AREA CODE <br /> 91 <br /> PERMIT NUMocR PERMIT APPROVAL DATE PERMIT EXPI ATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATEFILED <br /> 312 YES ❑ NO Cl BY, <br /> 0 <br /> PERMC� <br /> CHEC Y IT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <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 INFORYATI LY. <br /> \\ FORM A(3-2-88) `O <br />