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• rP <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> _ SSA <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 P ENTLY CLOSED SITE N <br /> O / o. <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE CT <br /> N <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) CY) <br /> FACILITY/SITE NAME I' A� -• I RE OF ADDRESS INFORMATION <br /> /rmB l —/,YAY44 <br /> M,•1 <br /> ADDRESS NEAREST CROSS STREET ✓Box to mSitate El PARTNERSHIP ❑ STATE-A6ENp <br /> 0 CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL COUMY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#. ITH AREA CODE <br /> 7 CA 9�37G � 0 - b d$� <br /> TYPE OF BUSINESS: ❑ @DISTRIBUTOR ❑ 4 EPA ID p CESSOR RESERVATION or ❑ #of HIS SI <br /> ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST FIRST) PHONE#WITH AREA CODE DAYS'. NAME LAST,FIRST) PHONE#WITH AREA CODE <br /> 4e2��� a�Q 7� =8 b—o67� <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ) I/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �` I <br /> El CORPORATION El LOCAL AGENCY [71 FEDERAL-AGENCY <br /> 107,0 /V ,L.•(� ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME I STATE ZIP CODE PHOHEp,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (OUST BE COMPLETED) f VFry '/V <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREETADDRESS */Box to irdicale 0 PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION 0 LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#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: I. ❑ II. ❑ 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# AGENCY# FACILITY ID It #of TANKS at SITE <br /> 14 O l /K 1 1� 1 ?) d / <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> o ;M MI <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> [CHEICK0 <br /> CATI NODE CENSUS TRACT#� SUPERVISOR-DIST ICT CODE BUSINESS PLAN FILED DATE FILED <br /> �.Py 3Z YES NO �J/ /�`�0 <br /> PERMIT AMOUNT SURCHARGE AM UNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEASL(t1 OR MORE TANK PERMIT FORM 'B'APPLICATION(S),USS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> w ORM A(3-2-88) • <br /> �� DATA PROCESSING COPY <br />