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STATE OF CALIFORNI11 WATER RESOURCES <br /> CONTRO�BOARD <br /> FORM "A': <br /> UNDERGROUND STORAGE TANK PROGRAM W Alt, <br /> SITE ITY/SITE, INFORMATION and/or PERMIT APPLICATION � <br /> ..rr , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE crpoaN/ <br /> MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F� <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CO <br /> FACILITY/SITE NAME W <br /> CARE OF ADDRESS INFORMATION <br /> &XVAJ5 Z&k* A,vC In T C7Giz <br /> C�NN(S <br /> ADDRESS NEAREST CROSS Sv/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /9,700 /vep Rejd �,(�� pJPr ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE SITE PHONE#,WITH AREA CODE <br /> Al ON CA <br /> TYPE OF BUSIN SS ❑ p DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID It <br /> ❑ 1 GAS STATION [03 FARM ❑ 5 OTHER TRUST LANDS of ❑ #of <br /> AT THHISIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) P� PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Nr g -�- _6 s"_ <br /> NIGHTS NAME(LAST,FIRST)/� PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> A/Nt ROIL <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME ,/_ CARE OFA KESS INFORMATION <br /> JV�f <br /> Gt G vmc' !4 G QNNis <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ElINDIVIDUAL 11COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> �� mN C-4 5366 <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. ❑ 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 /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> =_3 1 1 11 ET__ I I I I I f <br /> lo- <br /> -z <br /> IF 1- 1 k� <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE It WITH AREA CODE <br /> Alum I I- rT <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> .2,-3.a3 YES NO D // <br /> CHECK If PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <br /> By:, <br /> 6 Omni <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 0 <br /> FORMA(3-2-88) ' <br /> <�C/� • DATA PROCESSING COPY 0 <br />