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STATE OF CALIFORN WATER RESOURCES CONTROL BOARD £ <br /> FORM `A': '- <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE fi,qL,,jp RW" <br /> MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT 2-15"CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N <br /> CT) <br /> FACILITY/SITE NAM CARE OF ADDRESS INFOR pTION A�" <br /> ADDRESS 2,V <br /> y/ 7 NEAREST CROSS STREET ✓�frloWicale ❑ PARTNERSHIP Q STATE-AGENCY <br /> I a V ` it' ��� a�,,r?Ik ❑- tl CI�VIDUALION ❑ COUNTY-AGENCY GENCY ❑ FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PH NE 0,WITH AREA CODE <br /> o <br /> �v'A,e _a CA (5-7)43S- ffg? I <br /> TYPE OF BUSINESS: EVDISTRIBUTOR ❑ ROCESSOR l/13.<if INDIAN EPA ID 1 #of TANK'a <br /> ❑ 1 GAS STATION ❑ 5 T <br /> 3 FARM HER RESERVATION or <br /> TRUST LANDS ❑ /✓� AT THIS 517E <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE DAYS: NAME(LAST,FIRST) PH07#WITH AREA CODE <br /> Ief Lk ! d 3-`-R,6 71 5A <br /> NIGHTS- NAME(LAST,F ST) PHONE 9 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHC p WITH AREA CODE <br /> III 5L 51,4 5A 5 + <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAM ` A /1 CARE OF A DRESS INFORMATION <br /> ga <br /> 10*16 <br /> MA[UNG or STREET ADDRESS �✓�a"'o indicate ❑ PARTNERSHIP 1:1 STATE-AGENCY <br /> � CORPORATION ❑ LOCAL-AGENCY ❑ FEOEHAL-AGENCY <br /> IF 7J ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> (lpta 61 <br /> 2_6>0 <br /> f <br /> III. TANK OW INFORMATION & ADDRESS — (MUST BEC MPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AG€NCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE <br /> IH. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L II. III. 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# ID# #of TANKS atlo <br /> SITE <br /> ( <br /> lQ- <br /> 3 h Ir Eoe,-) 1 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE k WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E PIRATION DATE <br /> I <br /> LOCATION CODE CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST 11)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> 1 � FOHM A(3-2-88r <br /> DATA PROCESSING COPY <br />