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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 1"A' <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE F-3 3 Pj <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS r FR <br /> ,yE NEAREST CROSS STREET ✓ idiule 0 PAR9ERtAP ❑ SiAJF.pf>EN(,Y <br /> -31 3 1 rL Fn e {'/I on) r all Def GC GCJ u c01PO 10 O LOCAL.AGDO O RDML.AGM <br /> ❑ INDMOUAL ❑ ()DtWY-AGBI(,Y <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> S G 4v-y - CA JT 0S �o�Orj 8— / <br /> TYPE OF BUSINESS: ❑2 DISTPoBUIOR ❑4&PXESSORN EPA ID# A,�,. p <br /> F-11 GAS STATWN r-13 FARM 5 OTHER 7RUSTLANDS 0 El /l�f� ,w AT THIS SITE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> rn e ao — 6,s1/ <br /> NIGHTS: NAME(LA'ST__FI��RSTI^^ PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> '' <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S h b <br /> MAILING 91STREET DRESS ✓Box to ir,Eicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 1p El CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> R <br /> IV, I✓/AO d�Q `L--• ❑ INDIVIDUAL Cl COUNTYAGENCY <br /> CITYNAMEiJ2 STATE ZIP CODE PHONE N.WITH AREA CODE <br /> G c� aos w� <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S'ccrne a a r, ve <br /> MAILING or STREET ADDRESS -/Bo.to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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. 11. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> CCO = =OUNTY# JURISDICTION K AGENCY M FACILITY IDR 6If of TANKS at SITE <br /> CURRENT LOC AGENCY FACILITY APPROVED�AME/ 1 ,517131 PHONE#WITH AREACODECODED <br /> GR L 31 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIMTION DATE <br /> LOCATION;ODE CENSUS TRACT# VISUPERVIS/OR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED pp <br /> d 31 O L/ T a ZI I YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE 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(3-2-88) <br /> .� DATA PROCESSING COPY <br />