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or' . <br /> STATE OF CALIFORWA WATER RESOURCES CONTROL BOARD M." <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SST 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 EZ7 PERMANENT CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> S SoYvL Forms <br /> ADDRESS NEAREST CROSS STREET PATNOWP STATE AG.FNY <br /> ° o , IAA o M,LArFM <br /> O <br /> J/7 C 71114' R o mvuEl 14 <br /> CITY NAME ,+, STATE ZIP ODE SITE PHONE N,WITH AREA CODE <br /> `J CA 95a -3/� <br /> TYPE OF BUSINESS. 029 IBUTOfl ❑d PROCESSOR -/Box if INDIAN EPA ID N � �^ n SoI TANK'F <br /> ❑ I GA65TATION '3FARM ❑ RESERVATION or ❑ I /0 V�"`�— AT THIS SITE <br /> 50THER TRUST LANDS <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 /> Dvf�c ' ae4 5a-3 a <br /> NIGHTV NAME(LAST.FIRSTJ <br /> PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILINGor SqEET ADQ#ESS j ✓Box toindicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> D F13 INDIVIDUAL 13COUNTY-AGENCY <br /> CITY NAME r STATE ZIP CODE PHONE N,WITH AREA CODE <br /> k_L%vN c'-tW� a0 Ca-31a <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> a <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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. ❑ II. 111. ❑ <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 A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY K JURISDICTION A AGENCY R FACILITY ID N Al of TANKS At SITE " <br /> Y3 c = =] ICOM I M710O O <br /> CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE F WITH AREA CODE <br /> oso5�- <br /> VLOCATION <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT• SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED1114? 3 `� � YES NOa- ^PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT0 BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPUCATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> 3�a �p <br />