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- AX T.. <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARDS <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Y !fig <br /> LCOMPLETE THIS FORM FOR EACH CILITY/SITE � F©p�P, <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME 4b I ` CARE OF ADDRESS INFORMATION <br /> ADDRESS ,/'] NEAREST CROSS STREET wicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> (I'�f IJ �cm rF(3 � COAPQAATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL. ❑ COUNTY-AGENCY <br /> CITY NAME f ` STA�CA <br /> ZIP DF SITE PHONE#,WITH AREA CODE <br /> /71K1//ty! (�/a ZO <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ✓Box if INDIAN EPA ID # <br /> ❑ 1 GAS STATION ❑ 3 FARM jePROCESSOR <br /> OTHER TRUSRESETYLANDS ATION or ❑ AT THIS S1TE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE Or WITH AREA CODE DAYS: NAME(LAS FIRST)FIRST) PHONE#WITH AREA CODE <br /> tG 14 2-0-f- ��� d � ISL <br /> NIGHTS: NAME(LAST, RST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> I'd Do <br /> aZQ <br /> _ -©g U <br /> II. PROPERTY OikNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME , CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS x�y !/X.x to indicate PARTNERSHIP ❑ STATE-AGENCY <br /> © O '�.IjjjV CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> 1 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> � 121,11-13-RJE 1- - Q/ <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> � CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS Dl.".indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> _71/14tiv© EIKCORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <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: L ❑ 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 /> ECHECK# <br /> JURISDICTION If AGENCY# FACILITY ID# #of TANKS at SITE <br /> Im L I I Ll I I L010111blKE � oa3 <br /> _1 <br /> AGENCY FACILITY ID <br /> Tk APPROVED BY NAME PHONE li WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISO -DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> if YES NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY; <br /> mj <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 ONLY, <br /> FORM A(3-2-88) 00 <br /> DATA PROCESSING COPY <br />