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y,,;., . "1 <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD s <br /> h <br /> W' A <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITEO FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ i NEWPERMIT ❑ 3 RENEWALPERMIT [0 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 90 <br /> 1� <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACIIIT'/SITE NAME CARE ADDRESS INFORMATION <br /> WY Q� <br /> ADDRESS NEAREST CROSS STREET ✓8ai O,xiisle 0 PARTNERSHIP ATE'AGENCY' N <br /> ❑ CDAPDM110N 0 LOCAL-AGENCY FEDEW-AGENCY <br /> 3 OV v rTF s f J 11 INDMWAL 11 COUNTY MEN <br /> CITY�IAME /1 STATE ZIP CODE SITE PH�0 E#,WITH AREA CODE <br /> Lp^�,!/lI� CA 2oy/ ? ,`l- 3 87 S' <br /> TYPE OF BUSINESS: 2DISTRIBUTOR ❑4PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ 1 GAS STATION 3 FARM 5 OTHER RESERVATION or #of TANK's <br /> ❑ TRUST LANDS ❑ tu 14 ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME ST,FIRST)Z. APHONE#WITH AREA CODE YS'. N\CAME LA/uS�T,FIRST) PHONE p WWIITH AREA CODE <br /> w v l�7' ✓ /tet <br /> NI S: NA ( ,FIRST) IIHONE ITH AREA CODE NIGHTS: NAVE(I-AST,FIRST) PHONE MJ4H AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) y� <br /> NAME CAR OF ADDRESS INFORMATION <br /> 604- ganji <br /> MAILINGor STREETADDRESS r ✓Box to indicate Lip PARTNERSHIP STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE HONE#. ITH AREA CODE <br /> 13 o l/�'T/LD —/�C . ' 10-7173 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF AD RFrSS INFORMATION <br /> MAILI Gor STET gpDRE S ✓Box to,,in/'tl�ibc its, 0 PARTNERSHIP STATE-AGENCY <br /> FL10 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME �' STATE ZIPC E PHONE#,W MAREA CODE <br /> ,PC 15' CD P/'tV '� <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. E�r 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> ® 0 0 3 1 51 01 oe) 2' <br /> CURRENT LOCAL AGENCY FACILITY ID# APP RO D BY N PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE V PER IT EXPIRA ION DATE <br /> PCHEC <br /> TION CODE CENSUS TRACCTT## SUPERVI8OR ISTRICT CODE BUSINESS PLAN FILED DATE F LED 6 <br /> 23 L/ L l YES ❑ NO ❑ 7� 0 <br /> If PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> \\�E 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 LY. <br /> \\ <br /> FORMA(3-2-88) - <br /> VVV ` .I <br /> '`� DATA PROCESSING COPY V <br />