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STATE OF CALIFORNI�C WATER RESOURCES CONTRch'BOARD �• "F <br /> I I <br /> RM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m' o <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE °' i•a ne`r <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER MAN ED SITE M'a <br /> ONE ITEM ❑3 INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE CA <br /> CA <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) A <br /> FACILITY/SITE NAMECARE OFA RESS INFORMATION <br /> 'I RaAmll aro L Alf -INS <br /> ADDRESS1, NEAREST CROSS STREET IJ PARTNERSHIP ❑ STATE-AGING <br /> Z.&, I mRPUunaN ❑ LGCALAGBXY ❑ FEDEMLAGBICY <br /> INanlwu O COUNTY Ali <br /> CITY NAME SI. TATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> �'. ,v CA 95.1 G z —?917— <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR PROCESSOR '/Box if INDIAN EPA ID N <br /> RESE <br /> F-11 GAS STATION ❑ 3 FARM LJ 5 OTHER TRUSTVATION LANDS or 1:1R of TANK'! <br /> AT TRIS 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 /> AjI <br /> r. 2 -0100 <br /> NIGHTS' NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Ma &)S - Sl 0 <br /> 11. PROPERTY OWNER INF RMATION & ADDRESS— (MUST BE COMPLETED) <br /> P'i OF • CARE OF ADDRESS INFORMATION <br /> MAILING or 81 BEET ADDRESS Be.✓ to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCYX 11INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITYNAME I STATE ZIP CODE PHONE N.WITH AREA CO DE <br /> ml EdpN Cr! I 9ys5 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME - CARE OF ADDRESS INFORMATION ' <br /> liti <br /> BN <br /> MAILING or STREET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 'j Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> • O• 3 Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITYNAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> Shoe k cw o77 95206 2 oQ- <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. ❑ 1L ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION M AGENCY W FACILITY ID# R of TANKS at SITE <br /> 3 �l = = d / 5z odo <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE R WITH AREA CODE <br /> r <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA'1 N CODE CENSUS TRAACCTT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED <br /> 23, by J;21 YES ❑ NO ❑ U -� C# <br /> CHECK R PERMIT 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 ON <br /> ` FORM A(3^2-813 <br /> /) - <br /> J A/ �•' DATA PROCESSING COPY <br />