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F ,; ..- . , <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM ^ <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m; o <br /> T COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT :J 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ONE ITEM e5 7 PERMANENTLY CLOSED SITE <br /> 2 INTERIM PERMIT 0 q AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1V <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) 4 <br /> FACILITY/SITE NAME <br /> � NCxI 1( ^ O )ps noc OF ADDRESS INFORMATIOry <br /> ADDRESS 1j•{/_ U� <br /> NE EST CROSS STREET r✓/Ba to iMUTA ❑ PARTNERSHIP ❑ STATE.AGBI <br /> E I WRPoRATIQV ❑ LDCAL AGEND ❑ FEDERAL AGIR0 <br /> CITY NAME C Ll INDIVIDUAL ❑ COUNTY-AGEND <br /> STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA 9s3 6 CtNI- <br /> TYPE OF BUSINESS. 2 DISTRIBUTOR d PROCESSOR ✓ <br /> Box"INDIAN EPA ID # <br /> I GAS STATION 3 FARM 5 OTHEA RESERVATION or ❑ p/` , #o1 TAN <br /> TRUST LANDS Oi AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS: NAMLA T IFIRST) <br /> /om( I � PHONE WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) W041L b WITH AREA CODE NIGHTS: Nq'E( FIRST) <br /> U I" PHONE b WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFOR ATION <br /> e 3 Nd k�s res e /vo S <br /> MAILING or SETA R SS I ✓Box toiodicate PARTNERSHIP ❑ STATE-AGENCY <br /> 4�TR/Elra�'a�� Ct21lI CORPORATION ❑ LOCAL-AGENCY ❑ FEDER -AGENCY <br /> KKKJJJ ❑ INDIVIDUAL ❑ COUNTY-AGENCY LA fir, <br /> CITY N ME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> �1Io.(NLL+ Creel ' C 9Ys9g '%Is 3 -v <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> �SOM?— As IIII CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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.El <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYIN JURISDICTION# AGENCY# FACILITY ID IF IF of TANKS at SITE <br /> 3 <br /> 10 10 11 ylilil 101610101 <br /> EN(,�'V"L�OCAL AGrr��ENC!Y�FATC`I�L1IT{Y"T1ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL D PERMIT E%PIRATION DATE <br /> N <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI D <br /> - - .2'3, �� YES NO ��7 87 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT ECODE 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 /> FORM A(3-2-E8) - <br /> Pwt DATA PROCESSING COPY ..► <br />