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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ' "F <br /> A , .. <br /> FORM A : UNDERGROUND STORAGE TANK PROGRAM �" Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION &ELLPERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE C4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> r <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Yawl aae �n` /H, VCvn u 01AI <br /> ADDRESS NEAREST CROSS SjREE7 ✓I'mOntrak El PARTNERSHIP ❑ STAIE.AGENCY <br /> 76Y e�eG+er C N I/CJC�JT Cl C0.Gf ION o LOCAL AGENCY 0 FEDERAL.AGENCY <br /> h INDMI ❑ COi AGENCY <br /> CITY NAME <br /> S-F� kid 1 STATE ZIP CODE n SITE PHONE p,WITH AREA CODE <br /> TYPE OF BUSINESS J`< CA ��vJ� 2 V` pJ <br /> ❑ 2 DISTP18UTOR ❑ 4 PROCESSOR ✓Bud INDIAN EPA ID a O <br /> ❑ of TANK's <br /> I GAS STATION ❑3FARM Ea5 OTHER TRUSRESETLANDS <br /> ATION or ❑ OJJF AT THIS SITE Z <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 /> a,rauCIAL Jtn" 21 -11 U4,Kp'nii <br /> NIGHTS: NAME(LAST.FIRST, { PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> K v IWC 2 —�8'So �r kk,5ii <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS 80.✓Box to ocicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> S7 6 14 t� _ El CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY <br /> `+ (�(/� r INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAgMO STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 1�4e 52-0 2�r- -18SC� <br /> 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> Ya au Yawl <br /> MAILING or STREET ADDRESSI/Box to indicate 13 PARTNERSHIP ClSTATE-AGENCY <br /> ems,./.�(� ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> C UI INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN 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: I. ❑ II. gr 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 /> i <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION S AGENCY K FACILITY ID N If of TANKS st SITE <br /> O0Zz3 1 r7l Lia <br /> CURRENT LOCAL 711 FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> u <br /> 571 <br /> PERMIT NUMBER PERMIT APPROVAL D TE PERMIT EXPIRATION DATE <br /> N <br /> LOCATION CODE �SUS TRACOT N SUPERVISOR-DISTRICT CODE BUSINEB CY I YPLAN❑FILED NO <br /> ❑ DATE FILED a 9, <br /> CHECKN PERMIT AMOUNT SURCHARGE AMOUNT ME CODE RECEIPTN 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 ONLI <br /> FORMA(3-2-88) <br /> --1 DATA PROCESSING COPY y..a <br />