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o'er_ <br /> STATE OF CALIFORNIA WATER RESOURCES CONTRO BOARD a, <br /> FORM 'A': u " <br /> UNDERGROUND STORAGE TANK PROGRAM o <br /> SFMARK <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEfq D SITEE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 10 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> FACILITY/SITE NAME <br /> sGGS U - sch 00N <br /> EASHIG ElNEAREST GROSS STREET ✓Bmminctica@ ❑fyP11TNST AGE <br /> ADDRESS ElNCY <br /> rsh Ll <br /> LOCALAGENCY FEE -AGENCY CO <br /> V7 INDIVIDUAL ❑ COUI AGENCY <br /> STATE CODE <br /> wV�1 <br /> CITU NAME SITE PHONE p,WITH AREA CODE y <br /> S4 q G ¢�,,�, CA ao ARM 4 -`f3Yl <br /> TYPE OF BUSINESSp DISTRIBUTOR L 4 ROCESSOR ✓Box if INDIAN EPA ID # #of TANK' <br /> ❑ max/ RESERVATION or AT THIS SITE <br /> ❑ 1 GAS STATION ❑ 3 FARM lu/ 5 OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LAST,FIRST) RE <br /> PHONE#WITH AA CODE DAYS. NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> C '. /l /Y� <br /> p0-n PS a l�� r O PHONEk WITH AREA CODE <br /> NIGHTS' NAME(LAST,FI ST) PHONE#WITHAREA CODE NIGHTS'. NAME(LAST.FIRST) <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> FNEfZ <br /> MAILING or STREET ADDRESS ✓Box 10 I RATIIO ❑ LOCAL-AGENCY <br /> ❑ STATE-AGENCY <br /> ❑ CORPORATION OUNTAGENCY ❑ FEDERAL-AGENCY <br /> 3A r— I ❑ INDIVIDUAL Cl❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIL',CODE O PHONE#,WITH AREA CODE <br /> C YY <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> S G ���Qc�- �X�I00 � �✓i$fl'iC <br /> MAILING or STREET ADDRESS ✓Box W,Dd,Cale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> A ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> STATE ZIP CODE PHONE#, H AREA CODE <br /> CITY NAME <br /> C ' Q �, <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# #of TANKS at SITE <br /> [� DO lZ 1612, 17DDO <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> IOCATOION CODE CINS <br /> US TRACT M� SUPERVISOR-DISTRICT CODE BUSINESS rPEL$N F❑ILED NO ❑ OAT FILED <br /> CHECK# / PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# Op O-7LBY <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 /> \ FORMA(3-2-88) <br /> Lr DATA PROCESSING COPY �+f <br />