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STATE OF CALIFORNIA- WATER RESOURCES CONTROL'&OARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM =" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> i� <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> if fYn � /l d4 <br /> ADDRESS NEAREST CROSS STREET ✓E ;oscima ❑ PANRNBSIIP ❑ SAM AGENLY <br /> 186/ ` �[ ❑ WI mToN Cl LOC L A04CY ❑ FEDEM ISM <br /> p655 G , !JIW I ❑ INri1WAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE I.WITH AREA CODE <br /> CleweCA 75z2-7 - 3770 <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> RESERVATION or N of TANICN <br /> ❑ I GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE <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 /> c� ' f 107- 5 —?770 <br /> NIGHTS: AME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF``ADDRESS INFORMATION <br /> � <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> O YJOC D 5 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAM STATEZIP CODE PHONE N,WITH AREA CODE <br /> A S,Z3 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION J <br /> N ('Qtvt 4 'ems I ( 1 (��T <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERS ❑ STATE-AGENCY <br /> 13 CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE Al.WITH AREA CODE <br /> ("A X 5,22 Z -2_2717'70 <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. ❑ if. 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* JURISDICTION N AGENCY N FACILITY IDM M of TANKS at SITE " <br /> CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE M WITH AREA CODE <br /> ,'LEMF33 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LLOCATIONCODE CENSUS TRACT N SUPERVISOR-DISTIAICT CODE BUSINESS PLAN FILED DATEf FI D <br /> dO 33.20 YES O NO ❑ 1/ b 9?PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT a 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 /> M A(e-2-88) \ <br /> -10-�I �' <br />