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STATE OF CALIFORNIX WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM a �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> Nr <br /> 1 COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY T NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE SITEZ <br /> i0 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> orI3&( N <br /> ADDRESS e NEAREST CROSS STREET ✓g��rgSvUrala ❑ PARRIEPSHIP ❑ STATE AGENCY 0 <br /> �f/SPOPAiIOI ❑ LOCAL AGENCY ❑ FEDENAL-AGENCY <br /> N Cl INDIVIDUAL ❑ COUNIV AGENCY N <br /> CITY NAME STATE ZIP CODE SITE P ONE N,WITH AREA CODE N <br /> CA 52.1 <br /> TYPE OF BUSINESS: F-]2 DISTRIBUTOR F-] 4 PROCESSOR ✓BOX R INDIAN EPA ID NSEATION ` <br /> ❑ 1 GAS STATION ❑3 FARM OTHER TRUST LANDS DT ❑ AT THIS SITE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> S) azT-z(v2ifvn/ R <br /> NIGHTS: NAME(LAST,Fl;STI PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 5T9M6 N ,� <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OFA DRESS INFORMATION <br /> N <br /> MAILING or STREET ADDRESS a�✓By to radio to ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> IL/CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY N E STATEZIP CODE P ONE N,WITH AREA CODE <br /> 325-2loZ <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME ^ CARE OF ID RESS INFORMATION <br /> om 1-i <br /> MAILING or STREET ADDRESS /r/ ✓BBB1/mnt to i.dimte 1:1 PARTNERSHIP 11STATE-AGENCY <br /> I CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY <br /> U ❑ 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: 1. ❑ II. ❑ Ill, <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO LEDGE,IS TRUE AND CORRECT <br /> S E(PF1 ? UZCe E�T7,Q AJ I CS ATE <br /> / Tb: z�oqultil� Dz. SwT�ft <br /> LOCAL AGENCY USE ONLY 05o ) A•1 5/3! <br /> COUNTY N JURISDICTION R AGENCY N FACILITY ID N R of TANKS at SITE <br /> ® = = 1D <br /> CURRENT LOCAL AGENCY FACILITY IDN APPR D BY NAME PHONE N WITH AREA CODE <br /> %URC& <br /> PERMIT NUMBER PERMIT AP OV DA E PERMIT EXP TION DATE <br /> 9 <br /> LOCATION CODE CENSUS3TRACTN PERVIS R-DISTRICT CODE BUSINESS PLAN FILED DAT ILE <br /> CXECKN PERMAMOUNT ECE <br /> SURCHARGE AMOUNT FEE CODE YES �RIpTNO ❑ Y. <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($(, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY/, <br /> ORM A IS-z-BB) <br /> r-- DATA PROCESSING COPY <br />