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`�fi7'!r'rrf <br /> STATE OF CALIFORN <br /> WATER RESOURCES CONTROL BOARDo.— <br /> /"'E•'i��ie�•r�1 <br /> eh <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAMAILm <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE "c,FORx P �Q <br /> FMARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT In 5 CHANGE OF INFORMATION ❑ 7 PER ENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE CD <br /> CTI <br /> i, FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N <br /> N <br /> FACILITYISITE NAME CARE OF ADDRESS INFORMATION <br /> C—ie,4 �M 0 <br /> ADDRESS NEAREST CROSS STREET o wldicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 6eRfs �� CORPORATION ElLOCAL-AGENCY 1:1 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ODE SITE PHONE#,WITH AREA CODE <br /> ZIP <br /> CA JAS?-� `La —�j /l�11 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 CESSOR ✓Box it INDIAN EPA Ip 4SERATION f <br /> ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUSTT LANDS or ❑ AT THIS SITE r <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS- NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYSNAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> e' Icew <br /> NIGHTS' NAM (L AST,FIR ) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME � �esOfCARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ! ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 / ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME "� STATE ZIP CODE PHONE H,WITH AREA CODE <br /> [��/.v � rn /_& 7voy X13 I-Aff.-1421-4577A�z <br /> Ill. 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. 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# Al of TANKS at SITE <br /> L1 o 0 0 /I <br /> [CHECKN <br /> ENT LOCAL AGENCY FACILITY IDA / APPROVED BY NAME PHONE#WITH AREA CODE <br /> T NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> ION CODE CENSUS TRACT# SUPERVISOR-DISTRI T CODE BUSINESS PLAN FILED DATE FILED <br /> ! / 7z? 0-0 YES ❑ NO ❑ <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY., <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAS f)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), SS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-86} <br /> DATA PROCESSING COPY <br />