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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> Ci COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 21fCHANGE OF INFORMATION ❑ 7 PERMANE 7LY CLOSED 517E <br /> ONE ITEM 1:12 INTERIM PERMIT E]4 AMENDED PERMIT El TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) I <br /> FAC ITY/SITENAME CARE OF ADDRESS INFORMATION <br /> ' u <br /> ADDRErS1�S� 1U. ^ NEAREST CROSS STREET ✓BORb xdicate ❑ PAATNEASIP ❑ STATBAGDxY <br /> V " - NgVIWAl <br /> ON <br /> 13 LOCAL AGENCY❑ COUNTY-A(ENC/ ❑ FEOEPAI-AGENCY <br /> CITY NAME^J' STATE ZIP qQDE SITE PHONE p.WITH AREA CODE <br /> cA Saaa. Cao q�1 -83� <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR4P ESSOR -/Box If INDIAN EPA IDp <br /> RESERVATION❑ I GASSTATION ❑3 FARM OTHER TRUST LANDS ar ❑ ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST.FIS4^d,4 � 6A�4 NE p /H AREA�DE DAYS. NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS;_NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> tl X09 6� -/v437 <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Is i avL, Tn usfr ,a I Inc <br /> MAILING orSTREETADDRESS Q✓�B.oxxttoo indicate ❑ PARTNERSHIP 1:1 STATE-AGENCY <br /> �� `U • �Q�� / , IH INDIVIDUATRA ION 0 COUNTY AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> C Sao a o ft- MY <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SQmpe et s 0o Ear <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY }I` <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <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: I. ❑ ICK 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 B SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> C�UNTYY# JURISDICTION K AGENCY* FACILITY ID If If of TANKS at SITE <br /> IJI � = = 1O I l o q l �) I OO <br /> CURRENT LOL AG _S <br /> FACC'ILITY If APPROVED BY NAME PHONE a WITH AREA CODE <br /> I _S <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTFIACTp SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> (/ I jalx YES NO ❑ <br /> \ CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 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 /> �.7 FORM A(3-2-88) <br /> ,� DATA PROCESSING COPY w <br />