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STATE OF CALIFORAID WATER RESOURCES CONTR RIBOARD A <br /> SEPI �M1f <br /> v �y, <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMA TLY CLOSED!!] <br /> 1541 <br /> 1. <br /> ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) 00 <br /> N <br /> FACILITY/SITE NAMELp,, F i�Nt­_ CARE OF ADDRESS INFORMATION <br /> ADDRESS ' G F NEAREST CROSS STREET ✓Ew to irdiuO 0 PARTNERSHIP 0 STATE AGENCY <br /> _Z31 I O J!y2 u iA fe ❑ INGAV OA`IDN CON AGEN FEDERAL AGENCY <br /> CITY NAME L` STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> �I T7 CA 5 ZZ UC <br /> TYPE OF BUSINESS: ❑ ISTRIBUTOR F-14 PROCESSOR ✓Box if INDIAN EPA ID p <br /> RESERVATION or 1:1 - TANICD <br /> ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS ATT <br /> THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: AME(LAST,FIRST) PHONE k WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> E J � I <br /> NIGHTS: NAME(LAST FIRST) PHONE ft WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS V V ✓Box to indicate 0 PARTNERSHIP 0 STATE AGENCY <br /> �V( ClCORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> I Cl INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME /� I yy STATE ZIPCODE PHONE#,WITH AREA CODE <br /> 7 Ot <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME T CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to od,.Irte ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCALAGENCY0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS 1-11 <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. rk, 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 N JURISDICTION N AGENCY N FACILITY 10 N R of TANKS at SITE <br /> U / / 1010 10 <br /> 1 �L <br /> CURRENT LOCAL AGENCY FACILITY ID� LAPPROVEDBY PHONE N WITH AREA CODE <br /> PERMIT NUMBERI—/,JI /C!�/Jl '`7 PERMIT APPROVAL DATEIRATION DATE <br /> LOCATIO�C E CENSUSTRACTN SUPERVISOfl-DISTRICT LAN FILED DATE FILEDES NOIt-17 CHECK N PERMIT AMOUNT SURCHARGE AMOUNTRECEIPT N 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 />