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STATE OF CALIFORM WATER RESOURCES CONTRUL. BO. _D <br />FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br />SITE . FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br />l� COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />W': a <br />W rn AIL m <br />C"LIFORrN IP <br />MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLQSED SITE <br />ONE ITEM 2 INTERIM PERMIT E 4 AMENDED PERMIT 1-1 6 TEMPORARY SITE CLOSURE 11771 <br />1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />FACILITY/SITE NAME <br />CARE OF ADDRESS INFORMATION <br />CARE OF ADDRESS INFORMATION <br />-7 <br />,PPC / FIC%c U <br />3-01-r/ d N <br />�^ y� J- �' L-(�G"� t<•%� <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />ADDRESS <br />STATE <br />NEAREST CROSS STREET <br />✓ Box tordicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />GU❑FEDERAL -AGENCY <br />T E(D <br />VDIGN <br />❑ DIUACOUNTY-AGENCY <br />CITY NAME, <br />STATE <br />ZIP CQAESITE <br />PHONE #. WITH AREA CODE <br />_ <br />%U<k 10/V <br />CA <br />(�--1 <br />U <br />TYPE OF BUSINESS F_� 2 DISTRIBUTOR <br />7 4 PROCESSOR <br />✓ Box if INDIAN <br />EPA ID # <br />M of TANK's <br />GAS STATION � 3 FARM <br />5 OTHER <br />ATION <br />TRUST LANDS or <br />AT THIS SITE 3 <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />DAYS. NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />S5CW& D CW -,J-- <br />`70 1 ! - /&SJ <br />S: NAME (LAST. FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />rw\CD <br />�_ovum Mo qF / 1y57 <br />II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />C U f Fv_U CCU.w l_' N),UCfS COM ^r <br />-7 <br />MAILING or STREET ADDRESS <br />✓ Box to indicate ❑ PARTNERSHIP Cl STATE -AGENCY <br />❑ CORPORATION ❑ LOCAL -AGENCY Cl FEDERAL -AGENCY <br />�^ y� J- �' L-(�G"� t<•%� <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE #, WITH AREA CODE <br />T E(D <br />III• TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />C' <br />�C[) <br />-7 <br />MAILING or STREET ADDRESS <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />/ <br />�'� , / x. `� (� I <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME .4_7Try <br />�A2V /T 7 tNN�unlx� T -AL <br />STATE <br />� <br />ZIP CODE <br />I'A/ �- <br />PHONE #, WITH AREA CODE <br />T E(D <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. ❑ II. E <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 />COUNTYj# JURISDICTION K AGENCY k <br />CI <br />CURRENT LOCAL AGENCY FACILITY ID M <br />A I�C_OS C I <br />PERMIT NUMBER PERMIT APPROVAL DATE <br />FACILITY ID k <br />F, 1 7/� L-1 <br />APPROVED BY NAME <br />PERMIT EXPIRATION DATE <br />8 of TANKS at SITE <br />� <br />CrTo <br />-7 <br />, <br />PHONE N WITH AREA CODE <br />[L=OCATION CODE CENSUS TRACT k SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED DATE FILED p�YES ❑NO ❑ /�I�/HECK # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT # BY: c'7 / <br />T�IS 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 />FO M A (3-2-88) <br />1--- <br />