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STATE OF CALIFORNIA WATER RESOURCES CONTROL b'�ARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM o Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOI SITE F-a <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION III ADDRESS — (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓B Iowodo ❑ PABINOWIP ❑ 57ATEAGDO <br /> ef- ° pDnIDMIl"' ❑ LOCAL.AA xY ❑ ROEw.AGENc <br /> SAT ❑ WUNIY.m <br /> CITY NAME STATE ZIP CODE SITE PHONE*,WITH AREA CODE <br /> G k CA St S 1 6avj) 9 3i - (o,73,5- <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box If INDIAN EPA ID x / /J <br /> ❑ 1 GAS STATION 3FAFm El5OTHER TRUSTYLANDS ATION Or ❑ �rC AT THIS SITE Ql <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRE PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> O r!a xT a <br /> II. PROPERTY OWN R INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> -11412 4- <br /> lca PT O <br /> MAILING or STREET AD ESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ORATS CY' ° CDIVIDUALION ElCOUNT AGENCY 11 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> c5/4 we CA Psao 7 <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box lo- - e lK❑l PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ ORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> DIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X.WITH AREA CODE <br /> C'f� �saia 3l 935' <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. ❑ It. ❑ Ill. <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 k JURISDICTION N AGENCY N FACILITY ID R N of TANKS at SITE <br /> 39 = = I I 141111qlS] ooc2 <br /> CURRENT LOCAL AGENCY f5CILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER K� 'CI!'✓// PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 177 ^3 a� l� YES � NO _15— 9 <br /> CHECK* PERMIT AMOUNT SURCHARGE1131 UNT FEE CODE RECEIPT* BY: <br /> W 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. i <br /> FORMA(3-2-88) J` <br /> DATA PROCESSING COPY <br />