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STATE OF CALIFORNIA ' WATER RESOURCES CONTROL -Moe <br /> RD '"`' �'' <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM " <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - � " �o 0 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ""�I"fi"1�� <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ffF'CHANGE OF INFORMATION ❑ 7 CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1631 ­4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME n ^b a CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Boob ❑ PARTNERSHIP ❑ STATE AGENCY <br /> /� ^�� V DATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> / I Y I INONIOUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE 1ItONE/1,WITH AREA CODE <br /> CA /V//U- <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑1 PROCESSOR ✓ ox if INDIAN EPA ID x N PI TANK'N <br /> E] I GAS STATION ❑ 3 FARM ❑ 5 OTHER TTRUSTYATION LANDS or r-1 AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: AME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> t1j" co/ v/z vi <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA COOS <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> �- <br /> MAILING wSTREET ADDRESS ✓Box to intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> �d1/tM B f/L�i �.- <br /> MAILING or STREET ADDRESS ✓Box to intlicale ❑ PARTNERSHIP C STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE I 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. n I. ❑ 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 N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> = = = 1010411 Iqlal 100103 <br /> CURRENT LOCA7/L//�GEaNCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS,PUN FILED NO ❑ DATE FIL Lfl <br /> 2PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY <br /> ITHIS 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 /> ,Vnvt FORMA(3-2-88) <br /> DATA PROCESSING COPY / <br />