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STATE OF CALIFORNIA► WATER RESOURCES CONTROL <br /> s <br /> FORMI A: <br /> UNDERGROUND STORAGE TANK PROGRAM a(rom: ^wm <br /> SITE CILITY/SITE, INFORMATION and/or PERMIT APPLICATION ~o , <br /> Pic COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 ELBMANEf4TLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE C <br /> G <br /> J <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) - <br /> FAGLITY/SITE AM (`� CARE OF ADDRESS INFORMATION <br /> .1�le V!LPA <br /> ADDRESS _ NEAREST GROSSSTREET ✓Boo b arae ElPAAINERSHIP CIS1ATEAGENCY <br /> ❑ COMDAT10N ClLOCALAGEND ❑ FEDENALAGENCY <br /> ( V V 33 ❑ INDIVIDUAL ❑ CWNFRAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE <br /> U ha/115 CA y'3�5 2d - <_� <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Bax it INDIAN EPA ID N M of TANK'FESE <br /> ❑ I GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUSTY <br /> ATION LANDS or ❑ AT THIS SITE V <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME / lad �—• CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS AV•PN' ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 11ElCORPORATION CILOCAL AGENCY CIFEDERAL-AGENCY <br /> V 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME l&_ 6, /STATE ZIP CODE PHONE p.WITS REA CODE <br /> V m(jf_ \5 <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) OJ� p\ °t(1 <br /> NAME CARE OF ADDRESS INFORMAT— 'J <br /> MAILING or STREET ADDRESS ✓Bax to in0icale , L <br /> ❑ CORPORATION � �' / %Y <br /> ❑ INDIVIDUAL / C` �(�.�7 <br /> CITY NAME STATE ZIPL �',V /�(F/" \n(J-� r <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS ✓�V'`C" o'4' -�-TlW' LCL 1 <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION A L I'.)f�j III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY ,40INLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY R FACILITY ID N N of TANKS at SITE <br /> a d a -0 <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIO C E CENSUS TRACT SUPERVISOR-DISTRICT COD BUSINESS PIAN FILED GATE FILED <br /> to 2, YES ❑ <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> � IN <br /> THIS FORM MUST BE ACCOMPANIED BY jW(1)OR MORE TANK PERMIT FORM 'B'APPLICATI UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLYQ rye, <br /> / ORM A(3.2-88) <br /> DATA PROCESSING COPY <br /> l/l/ \ <br />