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STATE OF CALIFORNIP WATER RESOURCES CONTROL BOARD <br /> , <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION s <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE CD <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) (D <br /> FACILITY/SITE NA E CAREOFADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓But utla ❑ PAIRNEPS9P ❑ STATE AGENCY <br /> -7 ❑ CORPORATION 11 LOCAL-AGENCY El FEDERAL AGENCY <br /> `mlf ❑ INDIVIDUAL Cl CWNIN AGENCY <br /> CITY NAME STATE ZIP CODE TE PHONE N,WITH AREA COD,�E��ii <br /> CA �fX -66 716 <br /> TYPE OF BUSINESS: 2DISTflI6UTOR PflOCESSOP ✓RESBox i"NDIAN EPA ID a #oI TANK's �j' <br /> ❑ 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUSTLANDSATIODI ❑ AT THIS SITE�� <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST PHONE N WITH AREA CODE DAYS' NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> 1-729ex M41 S ) 9 S /v ¢ i a 25/ <br /> NI HTS: NAM (LAST,FI PHONE M WITH AREA CODE NIGHTS: ME(LAS FIRST) HONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME Q <br /> &_;7 <br /> _ CARE OF ADDRESS INFORMATION <br /> f � <br /> MAILING or STREET DRESS ✓Box Lo indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> O /� `fE/O O�INODIVDUALION 11 LOCAL-AGENCY 11❑ COUNTY AGENCY FEDERAL-AGENCY <br /> CITY NAME y/ STATE ZIP CODE PHONE#,WITH AREA CODE <br /> �lj I /�7 LP � . DUB <br /> Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME /� � � � CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bo ndical0 ❑ PARTNERSHIP Cl STATE AGENCY <br /> �^ � ) �� p� ORPORATION Cl LOCAL-AGENCY D FEDERAL-AGENCY <br /> N. LCxC t/( ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME z STATE ZIP CODE PHONE It,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. ❑ it. ' Ill. u <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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 310 1 / I / 10 10 1 U <br /> CURRENT LOCAL AGENCY FACILITY <br /> „ID/# APPROVED BY NAME PHONE M WITH AREA CODE <br /> /V <br /> PERMIT NUMBER PEMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TzRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED <br /> D �J G'1 / YES NO J.(P <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# B <br /> assail <br /> Y. <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 />