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SpP` `�lr <br /> STATE OF CALIFORNI WATER RESOURCES CONTROL BOARD <br /> FORM `A% UNDERGROUND STORAGE TANK PROGRAM iaN^ <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FAC ITY/SITE c9A"c"__P <br /> MARK ONLY ❑ 1 NEW PERMIT � 3 RENEWAL PERMIT CHANGE OF INFORMATION 0 7 PERMANE OSED SITE <br /> ONE ITEM 2 INTERIM PERMIT E] 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE Q(p 0) <br /> V <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) v <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> i6ff-i �—c o <br /> HIP STATE AGENCY <br /> ADDRESS NEAREST GROSS STREET v`Bma,rI Cl 0 CORPORATION D LOCALAGENCY 0 FEDERAL-AGENCY <br /> G S 7L ❑ INDIVIDUAL ❑ COUNIY"AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> L o CA `l5 330 00 se--,1 <br /> TYPE OF B ESB: 2 DISTRIBUTOR 4 PROCESSOR I/Box it INDIAN EVA ID a p of TANK'a <br /> 1 GAB STATION ❑ 3FARM RESERVATION or AT THIS SITE 3 <br /> 5 OTHER TRUSTLANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> Gi e5 Let on gj Ston aoi-poi-.1y <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME / ��1I CARE OF ADDRESS INFORMATION <br /> LT <br /> u r? S O i, /7�-C-c7 <br /> DD/�RESS L 0 ❑ <br /> ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> MAILING or STREET Ar LJ OX /S�p/� S. �/N 0 CORPORATION LOCAL-AGENCY FEDERAL-AGENCY <br /> fr D <br /> i ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> 709 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SGY v Q [tS zl- <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> Cl CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE it,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: L E 1L 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 8 SIGNATURE) I DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #o1 TANKS at SITE <br /> S © 3 U v v <br /> CURRENT LOCAL AGENCY FACILITY ID# LOY PHONE a WITH AREA CODE <br /> LfhGS /SPERMIT NUMBER PERMIT APPROVAL DATETION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVI�oL STRICF❑ILEO NO ❑ DATEFILED <br /> EDCHECKM PERAIITAMOUNT SURCH.•A.-.RRGE AMOUNRECEIPT If BY: n <br /> SCJ OFF <br /> THIS FORM MUS�CCCCOM ACCOMPANIED BY AT LEAST OR MORE TANK PERMIT FORM 'B' APPLICATION($), U THIS IS A CHANGE OF SITE INFORMATION ONLY. 01- <br /> FORM A(3-2-881 d�J n <br /> DATA PROCESSING COPY `1 <br />