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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM "° a �o Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE r <br /> ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / N <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) � <br /> FACILI SI ENAME CARE OF ADDRESS INFORMATION <br /> CL,0— Ma L G <br /> JI <br /> ADDRESS F/P.�' ��� CROSS TREET��, ❑ INDNIGUPAII� 11❑ LOXENSE1 O FEDE0.LLGAGDO <br /> CITY NAME STATE ZIP CODE 0 :5SD'E PHON i H AREA CODE <br /> �o -�07 <br /> WPE OF BUSINESS: ❑y DISTRIBUTOR ❑4 PR ESSOR ✓Box if INDIAN EPA ID `� <br /> ❑ 1 GAS STATION ❑3 FARM OTHER TRUSTVATION LANDS or ❑ -T�f J -7 3 — / ATT IS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ss e t GPo aoq 8�g�75 <br /> NIGHTS: NAME(LAST,HAST) FrHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S arn-t-. <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAMEwe CARE OF ADDRESS INFORMATION <br /> ' � ti�, �' l <br /> MAILING o,STREET A RESS fox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ['' CJ CORPORATION 11LOCAL-AGENCY 11FEDERAL-AGENCY <br /> • D 417S ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If,WITH AREA CODE <br /> C a0 q <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING in STREET ADDRESS -/B..to intlicale ❑ 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)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> i <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION K AGENCY R FACILITY ID R #of TANKS at SITE <br /> ® = = ID101115-171010010 <br /> CURRENT LOC AGENCY FACILITY 10 N APPROVED BY NAME PHONE N WITH AREA CODE <br /> u <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DIS ICT CODE BUSINESS PLAN FILED DATE F D <br /> a res ❑ No ❑ �Q a6 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT It 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(3-2-85) - <br /> `, DATA PROCESSING COPY `./ <br />