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� <br /> STATE OF CALIFORNIP WATER RESOURCES CONTROL'BOARD yER;.°a:; <br /> `T`sA <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE cam`FaR='p <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENT" 'I OSEYi SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE j <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> e , F, <br /> � c <br /> ADDRESS NEAREST CPOSS STREET ✓Box loindicale ❑ PARTNERSHIP Q STATE-AGENCY q- <br /> 1 .1[��1.C�. CORPORATION Q LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0,14,j � ❑ iNDI I0UAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> L_.0k" CA <br /> TYPE OF BUSINESS: 0 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK's <br /> 1 GASSTATIpN ❑ 3 FARM ❑ 5 OTHER RLSERTRUSTVATION LANDS or ❑ AT THIS SITE a <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PAYS: NAM (LAST,FIRST PHONE#WITH AREA COD DAYS' NAME(LAST,FIRST)\� ��PHO -E3#WITH�E��E <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 /> E t � 1 <br /> MAILI!��� STREET A�1ESS ✓Box to indicale El PARTNERSHIP ❑ STATE-AGENCY <br /> Y,`� ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME ( STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-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: I. IL ❑ 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&SIGNAT EI DATE <br /> LOCAL AGENCY USE ONLY <br /> FNUMIER <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> _-El 113161VI 1 0 cl/"9 (01 ""' <br /> FACILITY 10# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION S TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED NO ❑ D�T JEO _q <br /> RMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# Y: CEJ( !I <br /> THIS FORM MUST BE�CCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-68), <br /> DATA PROCESSING COPY <br />