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STATE OF CALIFORWA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> // COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> l,- <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 5eiNTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 6� ,z <br /> 10 <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> S_6o G/ -t-m iv Stee./ ro <br /> ADDRESS NEA"R�CROSS STREET ✓Bat'IS �� N ❑ PAI LOCkAGENV ❑ STATEVOCY _,4 <br /> AGDCY <br /> 3003 Jam, fila mhre r N, n,wA 99 D iNomxh D GOUM AGBIC( <br /> CIN NAME STATEZIP CODE SITE PHONE N,WITH AREA CODE <br /> to C. � CA q3a o r d 31 - 11751 <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ 4 PROCESSOR ✓ if INDIAN EPA ID# If of TANn <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER RESERBozVATION or ❑ n/ 0 N F AT THIS SITE <br /> RE <br /> TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(IAST,FIRST) PHONE#WITH AREA CODE DAYS: N E(LAST,FIRST) PHONE#WITH AREA CODE <br /> fao -4751 (ao&t)93 - 5 <br /> NIGHTS: NAME ,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST.FIRST PHONE#WITH AREA CODE <br /> L[ O <br /> Yne- <br /> ll. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S ocfftoyiS e - iV Cor <br /> MAILING or STREET ADDRESS ✓Bd4 to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> O O' [(CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> a D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> S C14 95a ao 231- q751 <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> so pr o ige-etu a L0 ki e <br /> MAILING or STREET ADDRESSIF ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CIN 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 13OTN LEGAL NOTIFICATION AND BILLING: I. ❑ II. 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) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> a 00 1 / 1 5 ' l 000 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE.k WITH AREA CODE <br /> S7�OGO <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACTT* SUPERV180R-(DyI8TRICT CODE BUSINESSPLANFILED DATE FILED <br /> a3, `'3 O � d YESNO 3 g <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M If I dy: <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(3-2-881 <br /> — DATA PROCESSING COPY —� c� <br />