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... .� .r++F-..... ...........-.�.vv.�,.—..+es-irx..m�w.m^�-T'q rrpR.Y•.-,.-vt..r..a-' oe�.... <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD IA <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION0 <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Lj � <br /> l c_n <br /> I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) v <br /> CD <br /> FACILITY/SITENAME CARE OF ADDRESS INFOR ATION <br /> S U (TP/JPS S /C 7I-Ce PAv/iN� <br /> ADDRESS NEAREST CROSS STREET ✓ ❑ STATEAGENCY <br /> 2315 S oizrc�o �/('/}- ❑ �y GO <br /> CITY NAME STATE CODE SITE PHONE K,WITH AREA CODE <br /> SfoC�C ON CA .2 �20 — —z11726 <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑4,PROCESSOR ✓Box if INDIAN EPA ID If <br /> RESERVATION or •of TANK's <br /> ❑ I GAS STATION ❑3 FARM5 OTHER TRUST LANDS ❑ /l,J I AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAY : NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> Ne <br /> Z0?-W7-3Y7f 6L962 <br /> NO TS: NAM (LAST.FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> U ry *kN <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME let If l-'Q z" c" 1JSITATE <br /> S INF 4:40)Q <br /> MAILING or STREET ADDRESS OYr cate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> S r ATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> G AL ❑ COUNTY-AGENCY <br /> CITU iErkkQ <br /> ZIP CODE PHONE If,WITH AREA CODE <br /> S 0 6 <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Zffle <br /> os <br /> MAIUNG or STREET ADDRESS ✓Boz to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL —11 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1.0 I1. ❑ 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 A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY p JURISDICTION a AGENCY# FACILITY ID If If of TANKS at SITE <br /> m I ed 1.,�7 1 4 O 16101olo <br /> CURRENT LOCAL AGENCY FACILITY ID p APPROVED BY NAME PHONE p WITH AREA CODE <br /> PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK <br /> CODE CENSUS pTRACT a SUPERVISOR-0ISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 23 O Q C YES NO C' <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT a 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 INFORMATION ONLY. <br /> FORMA(3-2-SB) <br /> DATA PROCESSING COPY .ted <br />