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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD sE '"""j <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM a Z <br /> S!T FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT F—] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSE <br /> 2 INTERIM PERMIT SITE F"� <br /> ONE ITEM ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N <br /> 1:1 NO <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CAPE OF ADDRESS INFORMATION <br /> g4j <br /> ADDRESS (�, NEAREST CROSS STREET ✓ IpirdiWe ❑ PARINETI311P ❑ STATE AGENLT <br /> 'S, T A ❑ ICC#OR LION ❑ L 17 CC ❑ FEDERAL AGM <br /> CITY NAME O V V r`� STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA a-lD S"JYCo7 <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box it INDIAN EPA ID <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHEfl TRUSTTYLANDS RESERATIONor ❑ play—p— M of TANK's O <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS-,NAMELASST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> LTLTVV�J�yIIPPIILL Levr I ?_171Q <br /> NIGHTS: NAME(I-AST FIRST-) <br /> -) n PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> SC � <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> eonswriv )I-- <br /> MAILINGorS -/REET ADDRESS 0.to <br /> inoicat. ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �[ El INDIVIDUALON El COUNTY-AGENCY 11 LOCAL-AGENCY FEDERAL-AGENCY <br /> CITY NAME STA ZIPDO� PHON�,WITH AREA CODE <br /> CODE <br /> III. TANK OWNER IN RMATION & ADDRESS — (MUST BEC MPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING of STREET ADDRESS -V B..to ird,cat§ ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.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. II. ❑ 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 /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY R FACILITY ID N #of TANKS at SITE <br /> = = = I60 5 1 q, I 8r D D <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT MBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> rCHECK# <br /> N CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F LED //'�11 <br /> YES NO aL-'' g^ <br /> U <br /> PERMIT AMOUNT SURCHARGEAMOUNTFEE CODE RECEIPT* BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONIS), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-86) (J <br /> w4wor DATA PROCESSING COPY �., <br />