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STATE OF CALIFORNO WATER RESOURCES CONTRYBOARD ::''E <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIO ° : o <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMAN TL CL ED SITE 1"a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ fi TEMPORARY SITE CLOGURE —4 <br /> 0 <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) W <br /> N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> �7 ER- ViCCS <br /> ADDRESS (',// //� NEAREST CROSS STREET ✓ xalr rete 0 PASTNERSHIP 0 STATEAGENCY <br /> / / A1,4- V Pt <br /> INDIVIDUAL 13 <br /> 11 11 CLOCAL <br /> NN AGENCY El FEDERAL-AGENCY <br /> C"iCITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> S7/0v CA S'20 66Z <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOfl ✓ROx if INDIAN EPA ID a /J <br /> ❑ TlON <br /> 1 GASSTATION [D3 FARM ❑ 5 OTHER TRUSTYLANDS 0 1:1AT THIS SITE (/ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME_(LAST.4FFIRST) PHONE#WITH AREA CODE DAYS: NALA�(IAST,FIRST) PHONE p WITH AREA CODE <br /> IA r 0" log <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 4 ' L.• <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S�IeJIc <br /> MAILING or STREET ADDRESS ��,.L, ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> O//��//�� FCS CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> VV ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP DE_ PHONE N,WITH AREA CODES <br /> 5 S — V <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME ^^^^ CARE OF ADDRESS INFORMATION <br /> WU <br /> MAILING or STREET ADDRESS '.I. <br /> Ioindicate 1-1PARTNERSHIP0 STATE-AGENCY <br /> CORPORATION 0 LOCALAGENCY0 FEDERALAGENCY <br /> INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIPCCDE 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. ❑ it. ❑ 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 k JURISDICTION# AGENCY R FACILITY ID M #of TANKS B1 SITE <br /> M = = I i a / Z-1 O 161 DO I O <br /> CURRENT LOCAL AGENCY FACILITY ID N / APPROVED BY NAME PHONE 0 WITH AREA CODE <br /> ST50A Z <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> E CENSUSS TRAACT K SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> [7 YES NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> vV <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 /> FIRM A(3-2-88) <br /> x�YL'b[/11 DATA PROCESSING COPY <br /> 1 <br />