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STATE OF CALIFORNhq WATER RESOURCES CONTRbCBOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -m I o <br /> 2 COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION F�017 PERMANENTLY CLOSED SITE F"a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURElffl � <br /> OD <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME 1� CARE OF ADDRESS INFORMATION <br /> ( N Yv <br /> ADDRESS IY� NEAREST STREET ✓B bnluoe 0 PANINERSIIP 0 STATEAGOV <br /> 1 C 1 1 D V" " `t , 0 INGNIOM 0 COLACY.AEGUIC( 0 fE0EA1l-AGDILY <br /> CITY NAME STATE ZIP DE SITE PHONE N,WITH AREA CODE <br /> -4or-- k+ors CAs�os y66- S`l� <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I <br /> RESERVATION or EPA ID p A TAN <br /> $; <br /> /' E Z <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ U <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> or N Bf1� 966 -C42 L(N <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 6(&6.j �� /- 6 1 UN <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> u o(f) U/ 0 olsot-j <br /> MAILING or STREET ADDRESS ✓ ox Io intlicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 2-- �Na.( CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> gi ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME r STATE ZIP CODE PHONE WITHAREACODE <br /> I.t C 5e2o y 66-i9z <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAM E7 'f:5 <br /> DARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box toinaicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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. ❑ I. ❑ III.❑ <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 N JURISDICTION N AGENCY R FOCILITY ID N N of TANKS at SITE <br /> 06 -zo T -�2_ DCVO <br /> CURRENZLOCAL AGENCY <br /> ENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMITNUMBER :7SUIICIIRGE <br /> ATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACTISOR-DISTRICT CODE BUSINESSPUN FILED NO <br /> ❑ DATEfILEO <br /> 1 Y CNECKN PERMIT AMOUNT AMOUNT FEE CODE RECEIPTM BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> ORM A(&2-SB) <br /> ...� DATA PROCESSING COPY a../ <br /> r <br />