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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> Zr A� .lhf <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM * <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 EEBMAUENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 0 <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) N <br /> FACILITY/SITE NA CARE OF ADDRESS INFORMATION <br /> cA(Z �, Kefcd Core 41 Crow <br /> ADDRESS <br /> NEAREST CROSS STREET Bw bixFme D PARTNERSHIP D STATE AGDO <br /> W1 l�A� o IE)BU <br /> YE. ki Orc � <br /> CITY NAM STATEZIP CODE SITE PHONE N,WITH AREA CODE <br /> le Pr�Tf"S CA SZ-2 20?-CJs y- z <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> RESERVATION or ( N of TANMN <br /> ❑ T GAS STATION ❑3 FARM ®5 OTHER TRUST LANDS ❑ U/../�NOCA,,/-/ AT THIS Slh <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) / <br /> DAYS:/(Z/N�A,M�E(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME LAST,FIRST) I PHONE#WITH AREA CODE <br /> acAJ / 2-0'7- 7 5 -_?_3,,Z q <br /> NIGHTS: NAME ST,FIRST / PHONE N WITH AREA CODE NIG{iT$�NAy.E(LAST FIS) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME /� CARE OF ADDRESS INMATION <br /> QCI K /`onp 'd / <br /> MAN 1-1 n.STREET A-ICFecox to mdlc.l. D PARTNERSHIP D STATE-AGENCY <br /> P, . <br /> L/ cRPORATION ❑ LOCAL-AGENCY 11FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STAT ZIP CODE PHONE#,WITH AREA CODE <br /> C/P C/v q5?2 20 - S 33z <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Or-, K COl C/dw <br /> MAILING or STREET ADDRESS ✓ ox to intlicate ❑ PARTNERSHIP OSTATE-AGENCY <br /> ��t,�� CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> ,6 , C) �]/J ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> C N#7ti� C 2-7-r7 <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. ❑ 11. 111. ❑ <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY11 JURISDICTION K AGENCY S FACILITY ID If N of TANKS BI SITE <br /> KM = = I d 012- 1p bd 10 <br /> CURRENT LOCAL OENCY'•^ILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL OA PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT• SUPERVI OR- (STRICT CODE BUSINESYPLAN f ❑FILED NO ❑ DATE FIZD2 3 �g n <br /> 20 1 C <br /> CHECK# 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 ONLY. <br /> FORM A(3-2-88) <br /> `W DATA PROCESSING COPY `II/ <br />