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STATE OF CALIFORNClrC WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND'.STORAGE TANK PROGRAM = " ` <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ,; o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5V w <br /> 0 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) N <br /> W <br /> FACILITY/SITE# E CARE OF ADDRESS INFORM N <br /> Le! r ooh <br /> ADDRESS r NEAB CROSS STRE$L — ✓80r.mirdli ❑ PPATNER9UP ❑ STATE- <br /> AGENCY <br /> YL�J1L-•-•jJ� CORPORATION ❑ LOCAL AGENCY ❑ FEOERALAGENCY <br /> w ❑ INDVIGunL D COUNTY-AGENCY <br /> CITY NAME C STATE ZIFdDE 1 SITE PHONE,WITH AREA COD <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a T) S 3 <br /> p of TANK'a <br /> ❑ 1 GAS STATION ❑ 3 FARM � HEfl TRUSRT LANDS ATION or ❑ AT THIS SITE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NA (LAST,FIRST) PHONE a WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> r ks Lei, 1 33ak <br /> NIGHTS'. N ME(LAST,FI`R_ST) _yb PHONE N WITTHHA�REA)CODE NIGHTS: NAME(LAST, US;w PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME ,/A I /160W CARE OF ADDRESS INFORMATION <br /> MAILING or S[IT_BE_FF��ILii OID ESS /l-• ✓Box t`r'o'inddcatte ❑ PARTNERSHIP D STATE-AGENCY <br /> UJ D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> T l/ D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAMESTATSa/f ZI�CO-DE PHONE#WITH AREA CODE <br /> 5 '► I A09 -IS9,2a <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> YYLJF �,� <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCALAGENCYD FEDERALAGENCY <br /> D INDIVIDUAL D COUNTYAGENCY <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. ❑ II�—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 /> COUNTY41 JURISDICTION M AGENCY# FACILITY ID N It of TANKS at SITE <br /> ® = = 1010 I al 19 1 ol Idol <br /> CURRENT LOCAL A ENCY FACILITY ID If APPROVED BY NAME PHONE N WITH AREA CODE <br /> E ►1 �2ZZ <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LLOCATqN i CENSUS TRACT# _ SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED D E ILED(.tel] (JSQVIYES NO iI 3ECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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) • • J/ <br /> DATA PROCESSING COPY <br />