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STATE OF CALIFORNIM WATER RESOURCES CONTROL BOARD <br /> A <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I o <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER ANENTLY/C�LOSED SITE F"J <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE J <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) C4TI <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Jm a 5 <br /> ADDRESS Ay' NEAREST CROSS STREET ✓BPNetiule 0 PARTNEPSIIP 0 STATE AGENCY <br /> 17 3�O O CORPOINDDWIDUA.0 13 ��_AGENY ❑ FEDERAL AGENCY <br /> CITU NAME �/ STATE ZIP CODE SITE PHONE p,WITH AREA CODE ; <br /> /I�.•cy-/fir— CAS <br /> I <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR '/Box if INDIAN EPA IO N R OI TANK'R { <br /> ❑ I GAS STATION ❑3 FARM ❑ B OTHER TRUSTVATION LANDS or ❑ <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE OAVS. NAME(LAST FIRST) PHONE M WITH AREA CODE <br /> I <br /> NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION j <br /> gNQkG C <br /> MAIUNQpr STREET ADDRESS ✓Bo to irid.ate 0 PARTNERSHIP 0 STATE-AGENCY <br /> PORATION 0 LOCALAGENCY0 FEDERAL-AGENCY <br /> C� INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> slli)ck�vlv C-4 sa 2 <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> i <br /> MAILING or STREET ADDRESS ✓Box to Inc 1c.t. ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M.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. r 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) CATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY R FACILITY ID a R of TANKS at SITE <br /> []E I 1 14/ � 10 <br /> CURRENT LOCAL AGlqCT,FACILITY IDR_ / APPROVED BY NAME PHONE a WITH AREA CODE <br /> PERMIT NUMBER �r/�]J11 K PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 2 3a2; YES [ NO <br /> CHECIC a PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT R 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 />