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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD yro. <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Io <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE IJ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT 1:1 6 TEMPORARY SITE CLOSURE cyl <br /> —4 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) ~ <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ,nl � <br /> ADDRESS //?� CEA�REST CI;OSS ST ✓80[IQON.II, 0 PAfRNERSHIP 0 STATE-AGENLY <br /> I2zq Ir • FV .N O NIDUALGN ❑ CDU WAGENG( ❑ FEi)EAALAGENLti' <br /> El LOCAL�04� <br /> CITY NA E STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> -(ee +0� CA S.Zo 204-v66--;43 <br /> TYPE OF BUSINESS: F-1 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box d INDIAN EPA ID p <br /> RESERVATION or X of TANK's <br /> ❑ 1 GASSTATION ❑3FARM 60THEfl TRUST LANDS ❑ AT TXISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LAST,f IRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ,DaWNpor, M <br /> IGHTS: NAME(LAST,FIRST) PHONE#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 /> M6 s S <br /> MAILING or STREET ADDRESS ✓Box to dicao ❑ PARTNERSHIP 0 STATE AGENCY <br /> 0 CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME W /V :f CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to,r,d,cate 0 PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 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. 1. ❑ 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 if k of TANKS of SITE <br /> 39 QTJlolol -adMiE lolololo <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 6-ooL 2 <br /> PERMITNUMBER LRMITPPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 23- YES � NO � jCHECK# PERMIT AMOUNTSURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> 1 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 /> \►J\I FORM A(3-2-M) <br /> DATA PROCESSING COPY �'� <br />