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-.-.rtr��-^.•vprr+. <br /> 5 8'. w. . t .ys <br /> STATE OF CALIFORN10 WATER RESOURCES CONTROBOARD r ar r•.\ <br /> f <br /> 4: t .t It <br /> FORM 'A': A <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> Z COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT L . ;HANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT u 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) I o <br /> F ITY/SITE NAME C EOFADURESSINFORMATION N <br /> d /3 /L19n/ A s <br /> ESS REST CROSS STREET Boy nixa* ❑ PARTNERSHIP ❑ STATE-AGENO CTI <br /> A/ I�'CSRPORATION 11LOCAL AGENCY 1:1 FEDERAL-AGM <br /> 1) INDIVIDUAL ❑ CAlIN1Y AGFNCY 00 <br /> NAME STATE CODE HONE p,WITH ARFA CODE 'A <br /> CA S33 u U - a- <br /> BUSINESS: ❑ 2 DISTRIBUTOR E—]4 PROCESSOR ✓Box if INDIAN EP N A <br /> E] 1 GAS STATION ❑3 FARM E] 5 OTHER TRUSTT LANDS RESERVATION <br /> dr ❑ /3 �( Cs AT THIS SITE / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> D VS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAV AME(LAST,FIRST) PHONE NWITH AREA CODE <br /> 9nI CAveK 3 a �e ColcX23-6f� <br /> IGHTS: NAME(LAST FIRST) HONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> N C OF`ADDRESS INFORMATION <br /> AM L TD P I-P /?a Al 3s-25s33s- <br /> INGorSTREETADDRESS ✓Box to indicate 11PARTNERSHI ElSTATE-AGENCY <br /> S� ❑ CORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> V t'/ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> AME TE CODE P NE k,WITH AREA CODE <br /> % AfllvfeL'A 9,53.36 2,3— 7�29 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NA C E OF ADDRESS INFORMATION <br /> 3! v <br /> LING or STREET ADDRESS Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> NAME ATE CODE Plt&NE#,WITHAREACODE <br /> 1 i <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 ❑ 11. ❑ 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 /> F <br /> ` OUN"k JURISDICTION If AGENCYIN — FACILITY ID k of TANKS al SITE <br /> 3 I I I I = fo D I cdobt <br /> C LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERM IT NUM BER PERMIT APPROV ATE PERMIT EXPIRATION DATE <br /> CCATI NN FODE CENSUS TRACT It S RVISORAISTRICT CODE BUSINESS PLAN FILED D FILED ���jjj <br /> YES NO ��� <br /> CHECKM RMIT AMOUNT SURCHAR AMOU T FEE CODE RECEIPTk BY: <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 ONLY. <br /> FORM A(3-2-88) <br /> • DATA PROCESSING COPY • <br />