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.v <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> 7 COMPLETE THIS FORM FOR EACH FACILITY/SITE on r <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION id 7 PERMANENTJ�CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 7/� � <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME pp������ 1 I CARE OF ADDRESS INFORMATION <br /> IYA.C(a �LVrr� DISC P EnN1AC-15 1 SmdlIi . i here`,iMnitit+I <br /> ADDRESS NEAREST CROSS STREET ✓Both Kink ❑ PAHINERSHIP ❑ STATE AGENC! <br /> pF��I COBPOPATIGN ❑ LOCALAGENCY Cl FEDERALAGEMY <br /> 6 S. a l�a OINGMWAI ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE A.WITH AREA CODE <br /> re <br /> 0I Cant CA 2-31 2M-496-S911 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUT R ❑ d PROCESSOR ✓Box it INDIAN EPA ID * It of TANK's <br /> TRUSRESETYATION LANDS of El UN <br /> ❑ 1 GAS STATION [:] 3 FARM �5 OTHER AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAM (LAST,FIRST) , PHONE IFWITH AREA CODE DAYS: NA E(LAST,FIRST) PHONE*WITH AREA CODE <br /> / T vn 6- 5 ( U <br /> NIGHTS. NAME(LAST.FIRST) PHONE*WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA CODE <br /> RI ( 2 _OSSN <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CAPE OF ADDRESS INFORMATION �1 <br /> �errAOLrGl,2 I e s Grc,44 11 ) <br /> MAILING OF STREET ADDRESS �� ✓BO indicate ElPARTNERSHIP ElSTATE-AGENCY <br /> X/30/R W f ❑ CORPP ORATION LOCALAGENCY ❑ FEDERAL-AGENCY <br /> IVIDUAL ❑ COUNTY-AGENCY <br /> CITY NIApQL -1 STATE ZIP CODE PHONE IF.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S ME <br /> MAILING a,STREET ADDRESS ✓Be.to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCYC FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE 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. ❑ 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 R JURISDICTION It AGENCY* FACILITY ID Al It of TANKS at SITE <br /> d Q l 11 2 ILI 10 10 Inj <br /> CURRENT LOCAL AGE CY Fj6tCILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMITR <br /> NUMBER� PERMIT APPROVAL DA E PERMIT EXPIRATION DATE <br /> N <br /> L <br /> ATION CODE CENSUSTRACTM SUPERVIS R-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> qcl23 0o2 YES 0 NO /l CK* PERMIT AMOUNT <br /> SURCHARGE AMOUNT FEE CODE RECEIPT* BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEASYAI OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ON <br /> FORMA(3-2-88) <br /> I-Re DATA PROCESSING COPY / <br />