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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> W: <br /> FORM ,A: UNDERGROUND STORAGE TANK PROGRAM = " <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> �v <br /> G COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONL F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT E�KCHANGE OF INFORMATION 7 PERMANENTLY CLOSED J'fE <br /> ONE ITE ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / Z <br /> .O <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> F IUTY/SITE NAME E OF ADDRESS INFORMATION <br /> ,�� 0 07 �9ivfhvDKEJF� CA. /�SZK ry <br /> REBS STGROSSSTHLET <br /> lKATE AGENCY <br /> N 11 LOCAL ❑ FEDERAL <br /> Y✓ OMmAO ❑ <br /> COUNtt AGENCY <br /> NAMESTATE CODE PHONE A.WITH AREA CODE <br /> r / <br /> TYPE OF BUSINESS. ❑ 2 01$ IBUTOfl ❑4 PROCESSOR ✓BOx it INDIAN ID d TANK-, <br /> RESERVATION or R of <br /> El I GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ /✓ /c/O�(/i AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> NAME(LAST,FIRST) PHONE d WITH AREA CODE NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> $ vM �a 72 _2Sj e, tiIAQ� U SLI <br /> GHTS: NAME(LAST,FIRS HONE p WITH AREA CODE HTS: NAME(LAST,FIRST) PHONE d WITH AREA CODE <br /> ,S e 2 6 �fjr <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> XON F ADDRESS INFORMATION /\'��A, , <br /> /7 /6�% 4 WA41 f? d /� U 7 Se1v/haP�71S g <br /> M NG or STREET ADDRESS Box To indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> U7 ❑ CO RATION ❑ LOCAL-AGENCY ❑ FED RAL-AGENCY <br /> IVIDUAL Cl COUNTY-AGENCY <br /> NAME TE ODE P WITH AREA CODE <br /> S9xl ,gil a1 0 1r 21 19 �SL 2�o <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> PARPPF ADDRESS INFORMATION <br /> _.Lrz:- 2/ s its 167 <br /> ING or STREET ADDRESS yA I/Box to intlicaie ❑ PARTNERSHIP ❑ STATEAGENCY <br /> / J� ❑ CORPORATION ❑ LOCAL-AGENCY RAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> NAME // S TE ODE P p.WITH AREA CODE <br /> IV GAL NOTIFICATION AND BILLING ADDRESS <br /> ECK 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 /> D <br /> LOCAL AGENCY USE ONLY <br /> Moral /0 <br /> VOtgMITNUMBER <br /> JURISDICTION R AGENCYR S� FACILITY IDR of TANKS et SITE <br /> 3L 10101glolm 101 (9102 <br /> GFjNC FACILITY IDR APPROVED BY NAME PHONE R WITH AREA CODE <br /> (37 <br /> IT APPROVAL DATE PERMIT EXPIRATION DATE <br /> I Lacy Nq <br /> ATION CODE ENSUB TRACT SU RVISOR-DISTRICT CODE BUSINESS PIAN FILED FILED /G <br /> D 23 -80 YES NO � 7! / <br /> CHECK A ERMIT AMOUNT RCHARGE AMOUNT FEE CODE RECEIPT N 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(3-2-88) <br /> /`/J' % . DATA PROCESSING COPY �1� <br />