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r 'STATE OF CALIFORNIA. WATER RESOURCES CONTROL BOARD <br /> FORM 'A'. af' "I <br /> UNDERGROUND STORAGE TANK PROGRAM oI <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION _' i <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY © 1 NEW PERMIT 3 RENEWAL PERMIT 1�fPE5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ❑ � I <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS „AA " NEAREST CROSS ST RE A- ACO: e ❑ PARTNLOCK AGENCY <br /> ❑ FEDERAGEN <br /> ADDRESS <br /> LGPogR17DN Cl LOCKLL-AGENCY ❑ STATE AGENCY LY <br /> HwY 20 C NI ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE I.WITH AREA CODE <br /> 7"rLAG�( CA 953'lo C?09) 836- 0(- f <br /> TYPE OF BUSINESS 2 DISTRIBUTOR 4 PROCESSOR ✓Rax,f INDIAN EPA <br /> �10 A I of TANK'F <br /> I REEEKI GAS STATION ❑ 3 FARM El OTHER TRUSTYLANDS or ❑ ��✓ v .� / J ) ( AT THIS SITE �J <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYSNAAME(LAST,FIRST) PHONE I WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE.7711 AREA CODE <br /> FETZ610 ON ) D_ (2pOl) `b36-o64p(JOAn PIN^NVEI- IFR K/ <4 r-794 -_7 II} , <br /> UIGHTS. NAME NOGp•1,IEMFIRST) PHONE 0 WITH N� �NE (415)5(ol-REA CODE TS. NAME W�- (�IRST) GI 1'fN/NTiPHONE <br /> lT1�JJWITH <br /> �I`/7Lr <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED)Nwvvl <br /> NAME CARE OF ADDRESS INFORMATION <br /> UN1ow OIL,co- or LAur-oR-NIA) 0155"U00 <br /> MAILING or STREET ADDRESS lzmp, �' 1,�, /_�� to rFA Fle Cl PARTNERSHIP ❑ STATEFEDERAL <br /> ENCY <br /> AGENCY <br /> 2175 N� G�J�O !L CORPORATION ❑ COUNTY GEN ❑ FEDEREACOOFC <br /> INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE WITH AREA CODE <br /> WAL�.IL>(G2E�� Gt6_1 9459(0 44155 945- 1676 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> UNION flIL• 4D- <br /> MAILING <br /> °MAILING Or STREET ADDRESS ^ n r ,/n• / RSHIP 0 STATE-AGENCY <br /> L�pRPOMTION 11LOCAFLEAGENCY ❑ FEDERAL-AGENCY <br /> 21�iL ND � _(�VF V F� rJ1i1 Y I/ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> ClrySTZ14iWIT� EA 7wk,wGA 9459� � 6 +6- 67( <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. ❑ If. 9 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> AP (CANT' NAME(P INTER&SIGNATURE) OgNbjgo6fOV4N1 pemr H. `t DATE <br /> pS`AG. Lc�NSUL"D'-t�(fSFQR-UuO�PL.) 4��I � yO <br /> LOCAL AGENCY E ONLY <br /> COUNTY N JURISDICTION M III AGENCY N FACILITY ID N N of TANKS at SITE f <br /> CURRENT LOCAL AGENCY FACILITY ID I APPROVED BY NAME PHONE I WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECKL4 <br /> CENSUS TRACT Al SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES E] NO <br /> PERMITAMOUNT SURCHARGE AMOUNT FEEC ODE RECEIPT BY: <br /> THIS FORM MUST BE ACCOMPANIED BY ST(1)OR MORE TANK PERMIT FORM 'B'APPLICATI UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br /> r <br />