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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD '."""" <br /> fA <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM ro <br /> S7A� <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °'��.oce`r i <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURET51 1 Z <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) 10 <br /> FACILITY/SITE NAME t CARE OF ADDRESS INFORMATION <br /> /eS An me, _ <br /> ADDRESS NEAREST/ / NEA/R,ESST,CROSS R ET ✓Boa0 mule ❑ PARTNER'HP ❑ STATEAGDO N <br /> '3 7 1 j'1/ W* A �4, ❑ w IVIouuGN 13 LOCA <br /> -A� ❑ FEDERAL-AGENCY 00 <br /> CITY NAME STATE ZI ODE SITE PHONE#,WITH AREA CODE <br /> 9(;L 36, -no <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box 4INDIAN EPA ID N <br /> ❑ 1 GAS STATION 3 FARM �y(OTHFA RESERVATION or ,A/�� y po/TANK's pg <br /> ❑ 5? TRUSTLANDS ❑ /w l/ N"`- AT THIS SITE `1 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIR9T) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME_40 130 W I eS CAPE OF ADDRESS INFORMATION <br /> i <br /> MAILIN or STREETADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> w,,.,x�A Lyl . ❑ PORATION 11LOCAL-AGENCY13FEDERAL-AGENCY <br /> WI,• DIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE#,WITH AREA CODE <br /> L Cr4 q15 D 0flq 369-GGo/ <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Q owner <br /> MAILING or STREET ADDPESS ✓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. II. 111. <br /> u ❑ ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDG ,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# TY IDB Bot TANKS at SITE <br /> al = = v a 3 2- s OOZE <br /> CURRENT LOCAL AGILITY ID# APPROVED BY NAME PHONE 0 WITH AREA CODE <br /> PERMIT NUMBER PERMIT"PiRdVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILED <br /> D A87LO YES ❑ NO ❑ �fw <br /> CHECK If 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 <br /> Vj <br /> FORM A(3-2-88) <br /> �� DATA PROCESSING COPY �- <br />