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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> A <br /> FORM 'A': � Z <br /> UNDERGROUND STORAGE TANK PROGRAMro <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> tea 1 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE III <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) A <br /> FACILITY/SITE NAM CARE OF ADDRESS INFORMATION <br /> F R,144 C4, <br /> ADDRESS NEAREST CROSS STREET ✓Bumodrale 0 PARTNERSHIP D STATE AGENCY <br /> cly t 0 CORROU71ON D LOCALAGEND D FEDERALAGENCY <br /> lo, ❑ INDIVIDUAL D COU"AGENCY <br /> CITY NAME ' ^ STATE ZIP CODE SITE PHONE k,WITH AREA CODE <br /> LL� di CA 171 1A <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID p <br /> RESERVATION or X of TANK' <br /> ❑ 1 GASSTATION FARM E:] 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS.nnNAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE it WITH AREA CODE <br /> C- <br /> NIGHTS'. ME(LAST,FIRSTf PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> I ( IL I I <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME ,.y. CARE OF ADDRESS INFORMATION <br /> e s l <br /> MAILING or STREET ADDRESS o. Bax aril ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> L 0 C PORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 1 DIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME ZIP COOS-F/ IW�yoITH A J ~^� <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE`lCOMPLETED)5 ( C/ <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY <br /> 0 INDIVIDUAL D COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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: 1. ❑ IL ❑ 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# AGENCY# FACILITY ID If At of TANKS at SITE <br /> = = = l0lolzWloff 1 ,01610101 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> -/. f 3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> M <br /> LOCATIONODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED � t <br /> \ . 3A I YES NO 7 LI i 0 <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# Y: \ <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 INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> aw DATA PROCESSING COPY "am, <br />