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SE^auYe� 'fit <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD I <br /> W. <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> ficI o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> I <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT bd5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDSITE F-� <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE -4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) tV <br /> N <br /> FACILITY/SITEENNAME CARE OF ADDRESS INFORMATION <br /> -ef- <br /> ADDRESSNEAREST OBS STREE ✓ WWSi®R ❑ PA61NEF6xIP ASPIC( <br /> STATE AGE <br /> 3t7577 a). <br /> L?W#N /�rie /.tICOII✓ OPqu�ox OnAx 13 mERu.ACExa <br /> j CITY NAME STATE Z CODE SITE PHONE x,WITH AREA CODE <br /> 40 CA zOs 20Q-9Y3 2 <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I/Box if INDIAN EPA ID ft <br /> ESEE] 1 GASSTATION [:] � <br /> 3 FARM S{1THEfl TRUSTYLANDS ATION x ❑ ATT IS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE j <br /> N3-J79,777 aKAJ <br /> NI S:CNAM (LAST,FIRST) PHONE N WITH AREA CODE NIGHTS- NAM (LAST,FIRST) PHONE#WITH AREA CODE <br /> 3- �tk� <br /> II. PROPERTY OW ER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING ar STREET ADDRESS ✓ ox to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> L '7 / CORPORATION ❑ LOCM-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE d.WITH AREA CODE <br /> c,0ua/V cl+ S- 06 11,072"Y"01772 <br /> 2 <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> z5 As <br /> MAILING or STREET ADDRESS ✓Box to,nd,calo ❑ PARTNERSHIP ElSTATE-AGENCYE] CORPORATION ❑ LOCAL-AGENCY Cl FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <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: 1. ❑ 1164 <br /> Ill. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRU AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION B AGENCY B FACILITY ID It #of TANKS at SITE <br /> a 1010 1 • 1,0101010 1 <br /> CURRENT L CA AGENJSY AGILITY 1 M APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER CC/YLV'//�JJ, PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LHECK# <br /> ODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT/FI EDD <br /> YES NOPERMIT 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 /> M A(3-2-88) <br /> SBI DATA PROCESSING COPY �+a <br />