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STATE OF CALIFORNIX WATER RESOURCES CONTROL OARD <br /> v <br /> FORM 'A': <br /> STORAGE TANK PROGRAM Xao <br /> SITE FACI�F TE, IN ATION and/or PERMIT APPLICATION <br /> "r COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLYNEW PERM ^d ❑ 3 R EWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE x <br /> ONE ITEM 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE a <br /> I. FACILITY/SITE INFORMkT — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> �� �ti► �R� F, y6 <br /> ADORES s— <br /> NEAREST CROSS STREET gpe OT ❑ AA [I STATE-AGENCY <br /> ORATION 13 LOCAL AGENCY El FEDERAL AGENCY�� ` P0p5W1�C KKKINOMOUAL 13 COUNT( <br /> CITY NAME STATE ZIP CODE TE PHONE p,WITH AREA CODE <br /> SToc,KTon/ CA SZ03 ZOq 4- :3-9973 <br /> TYPE OF BUSINESS. },❑ 2xDISTRIBUTOR ❑.d PROCESSOR ✓Box it INDIAN SPA ID p <br /> �y t I(ESERVATION or - #of TANK'* / <br /> ❑ I GAS STATION ❑3 FARM ❑5 OTHER TRUST LANDS El THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYSNAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> yoST �JS7 <br /> NIGHTS'. NAME(LAST,FIRST( PHONE N WITH AREA CODE NIGHTS NAME(LAST.FIRST) PHONE p WITH AREA CODE <br /> ST Jf��nEs 1=• (2�'7 (03- 997 yoST =Gl AF3c.-14 2�i ¢b3 -`I973 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME �� A�T� CARE OF ADDRESS INFORMATION <br /> MAILING orr/S�TTREET ADDR SS ✓Box to ird,..te ❑ PARTNERSHIP 0 STATE-AGENCY <br /> /T 2/ fiR6 0AW PR ❑ NDIV DUALION 0 LOCAL-AGENCY 11 El COUNT AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If,WITH AREA CODE <br /> S`al-K7Z::)l✓ Cq �52rJ3 CA 95Lfl3 (20D ¢6,3-9973 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ' ✓Box toinCicate 13 PARTNERSHIP ❑ STATE-AGENCY <br /> 2 / ����✓v1 "IN./n/� ❑.L�ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> DIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> ��GK r0/J _A -5 2�3 CA '�S2 2�+ 3-99 3 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(l)BOX INDICATING WHICH ABOVE AOPRESS SHOULD BE USED FOR 001001 LEGAL NOTIFICATION AND BILLING: I: ❑ -- IC 111.❑ <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 /> �,4AA as F. os- / 9 90 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION M LAdENCY# FACILITY ID X R of TANKS at SITE <br /> 3 <br /> CURRENT LOCAL AGENCY FACILITY ID* APPROVED BY NAME PHONE*WITH AREA CODE <br /> PERMIT NUMBE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT j/A'� SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE <br /> LL 3 0u- 3a YES 0 NDE] Al r�3 1) <br /> p CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY <br /> THIS FORM MUST BE ACCOWANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM IBI APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> W1 FORMA(3 2-88) I <br /> -"k <br /> " 0 '"aar DATA PROCESSING COPY <br /> l <br />