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E^ <br /> STATE OF CALIFORNIP WATER RESOURCES CONTROBOARDt <br /> f, •4��lx�'•.�A <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAMft <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> lk <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER ANENTLY CLOSED SITE I"+ <br /> ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q�— rV <br /> CCl� <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> IV <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Po—C_ <br /> ADDRESS �j /. NEAREST CROSS STREET ✓ oto indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION [] LOCAL-AGENCY 1-1FEDERAL-AGENCY <br /> v V Y 4 /y <br /> T 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> s4c) G CA D <br /> TYPE OF BUSINESS: ❑ 2 DISTRIHLITDR ❑ 4 PFOCESSOR ✓Box if INDIAN EPA ID N <br /> RESERVATION or #of TANK's <br /> ❑ 1 GAS STATION ❑3 FARM OTHER TRUST LANDS ❑ F" AT THIS SITE f <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS, NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS, NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> T NI" -Peh 777 <br /> NIGHTS: NAME(LAST,F T) PHONE N WIT AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS aztc indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �y CORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> / 4C Y W1 r ptV RyW. INDIVIDJAL ❑ COUNTY-AGENCY <br /> CITY NAME STATEZIP CODE PHONE#,WITH AREA CODE <br /> __ 4" � CIS 7Cn ("fib �3 - 7.3 <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sa ,rue_ Q S azbvilt_' <br /> MAILING or STREET ADDRESS ✓ to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> { CORPORATION ❑ LDCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME ST(ATTE ZIP CODE ^''yy PHONE#,WITH AREA CODE <br /> FI�E <br /> /4 7s37 <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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS a1 SITE <br /> m I I I I EI I I lo lo 9 6 Fl Lo I 0 <br /> CURRENT LOCAL AGENCY FACILITY IDk APPROVED BY NAME PHONE k WITH AREA CODE <br /> AcG 1<0 <br /> S eq Fo/e <br /> PERMITNUMBER � PERMIT APPROVAL DATE PE741T EXPIRATRMIAA <br /> In I 1 f <br /> LOCATION CODE CENSUS TRACT k SUP RVISOR-DISTRICT CODE BUSINESS PLA FILED DATE FILE / �}p <br /> V 1 �3 : 00-0) a 41 YES [:] NO [:] /L) t t? © t3 <br /> CHECK k PERMIT AMOUNT SURCHARGE AMOUNT [FEE CODE RECEIPT# *BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO RM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA 13-2-158J 0 <br /> DATA PROCESSING COPY 0 <br />