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I <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �41p 0#M�F <br /> I <br /> MARK ONLY <br /> ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE M <br /> ONE ITEM ❑Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE KO 7 <br /> N <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORM)TION <br /> N2lup, \0 0 <br /> ADDRESS NEAREST CSTREET wlW11 PARRIP ❑ STATE.AG-ec3366 If Omo4 TMOOUDrGBV ❑ FSERASA000 <br /> CAN ❑ woi <br /> CITY NAME STATE ZIPCODE SITE PHONE N,WITH AREA CODE <br /> 5�40ck-6j CA 91 <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ 4 PROCESSOR I '/Box if INDIAN EPA ID# <br /> RESERVATION or - N of TANK's <br /> ❑ I GAS STATION ❑3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITIQ__ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) q, PHONE#WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE N WITH AREA CODE <br /> K06021- e `S- UN <br /> NIGHME(LAST,FIRST ONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> JTS' NAe _2Q UN <br /> II. PROPERTY OWNER INF M ION ADDRESS —(MUST BE COMPLETED) <br /> NAME Some As Am< <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS -/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING or STREET ADDRESS ✓Box to irWicale 11PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME $TATE ZIP CODE PHONE N,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: I. 0 II. ❑ III,❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION If AGENCY# FACILITY ID k #of TANKS at SITE <br /> = = C� iaa , d � Oho <br /> CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE Al WITH AREA CODE <br /> C <br /> PERMIT NUMBER PERMIT APPROVAL PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 23 U YES NO 0 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE pECE1PTN 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 /> FORM A(3-2-BB) J <br /> DATA PROCESSING COPY <br />