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STATE OF CALIFORNIA' WATER RESOURCES CONTROL-96ARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITETION FACILITY/SITE, INFORMATION and/or PERMIT APPLICAz <br /> Z COMPLETE THIS FORM FOR EACH FACILITY/SITE -_ 1 <br /> rd <br /> C9A�vOPN'P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE IJ <br /> ONE ITEM ❑ 2 NEW <br /> PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE SQ N <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME as <br /> CARE OF ADDRESS INFORMATION CO.t�S•+ If'a,� <br /> C o to <br /> ADDRESS ICG <br /> NEAREST CROSS STREETt''(�� ✓gasp vtliwk ❑ RAWNSMIP CIUA7 AGENCY <br /> S& I NU S V I] IIDNI <br /> El CORPO AlDN ❑ fgIINN AGS IllFEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> Lod <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR -/Box if INDIAN EPA D #A $ <br /> 1 GASSTATION3 FARM 5 OTHER RESERVATION or ❑ y t( T #of TANK's <br /> AT <br /> EMERGENCY CONTACT PERSONN((PRIMARY) TRUST LANDS EMERGENCY CONTACT PERSON(SECONDARY)THIs SITEI <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> C(A, ti ti <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> uN <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADO ESS INFORMATION <br /> 1 /C P <br /> MAILING or REET A��R/ESS ♦ ✓Box to indicate El PARTNERSHIP ❑ STATE-AGENCY <br /> 22-11" W� ��e �� ❑ CORPORATION CAL-AGENCY ❑ FEDERAL-AGENCY <br /> VV ❑ INDIVIDUAL COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE ONE p. ITH AREA CODE <br /> ZOW C ,v 209 335 - d 3 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMES Me- /fs CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If.ff 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) GATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# If of TANKS at SITE <br /> ® 02 � 1d 10 10 <br /> CURRENT LOCAL AGENCY FACILITY 10 If APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> N# <br /> LOCATION CODE CENSUS TRRAACCT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 2 23.�b �yz) YES NO G,rrf /I/ rI <br /> CHECK# PERMIT AMOUNT SURCHARGE 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 /> DATA PROCESSING COPY <br />