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STATE OF CALIFORNha <br /> FORM `A': WATER RESOURCES CONTR <br /> SITE UNDERGROUND °BOARD ter;f <br /> FACILITY/SITE INFORMATION <br /> TANK PR <br /> NFORMATION and/or PERMIT OGRAM ; <br /> COMPLETE THIS FORM FOR EACH FgCE =mfr m <br /> MARK ONLY ❑ 1 NEW PERMIT APPLICATION o .... �e Z <br /> ONE ITEM ❑3 RENEWAL pERMIT �. . I C) <br /> ❑ INTERIM PERMIT ❑5 CHANGE OF IN FORMATION <br /> 1. FACILITY/SITE INFORMATION & ❑4 AMENDED PERMIT <br /> ❑6 TEMPORARY SITE CLOSURE RMANENTLY CLOSED SITE 1..6 <br /> FACILITY/ ENAME ADDRESS— (MUST BE 3 <br /> y^ COMPLETED) 0 <br /> ADDRESS n l.. CARE OF ADDRESS INFORMATION 2� ORMATION I <br /> ^ V i <br /> CITY NAME�O � �Y��� K� NEAREBT CROSS STREET k— <br /> i <br /> D ✓ ❑ PARTNERSHIP <br /> ❑ LGGAL ❑ STAIEAGBI0, <br /> 11 TYPE OF BUSINESS; STATE INGAGENLY MGUAL ❑ GGUNTY-AGENCY ED] FE AGENCY <br /> 2 DISTRIBI/TOfl ZIP ODE❑4 PRESSOR ✓ CA r�'(l SITE PHONE 1.WITH AREA CODE <br /> I STATION ❑3 FARM F-�� BOX if INDIAN EPA ID # <br /> EMERGENCYL_IJ OTHER RRUST LANDSON Or ❑ - tA n�. <br /> CONTACT PERSON(PRIMARY) At Of TANK•X <br /> DAYS: NAME(LAST,FIRST) EMERGENCY AT THIS SITE (� <br /> n PHONE It WITH CODE CONTACT PERSON(SECONDARY) <br /> NIGHTS: NAME(LAST,FIRST) DAYS' NAME(LAST,FIRST) <br /> -- PHONE#WITH AREA CODE <br /> PHONE p WITH AgEA CODE NIGHTS: NAME(LAST_FIRST) <br /> 11. &ADDRESS — PHONE aWITH AREA CODE <br /> PROPERTY OWNER INFORMATION i <br /> "AME (MUST BE COMPLETED) <br /> OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS l� vR(nU <br /> CITY N I y!n to intlicale ❑3 PgRTNEgSHIP❑ NO V DUALION ❑ LOCAL-AGENCY ❑ <br /> STA C -AGENCY <br /> FEDERAL AGENCY <br /> �. �J ❑ OUNTY <br /> (Ad ZIP CODE PHONE#,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) H <br /> NAME S /5a'y1,`�' (2am' -TE- CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS lA <br /> ✓Brix10 intlicale ❑ PARTNERSHIP <br /> CO <br /> CITU NAME ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDER L-AGEN <br /> ❑ INDIVIDUAL ❑ COUNTY- ❑ FEDERAL-AGENCY <br /> STATE AGENCY <br /> ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)SOX 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 OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED B <br /> 7!����dt:6T <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION k AGENCY k <br /> /\)FACILITY ID k Al Of TANKS at SITE <br /> CURRENT LOCAL ENCY FACILITY ID k V I V O <br /> - F-n ,�Z APPROVED BY NAME PHONE k WITH AREA CODE <br /> PEgMR NUYBER '` PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRAL,*M SUPERVISOR-DISTRICT CODE <br /> 3 t BUSINESSP g N FILED <br /> L J VVVVV LIJJ DATE PILED <br /> CHECK R PERMIT AMOUNT ❑ NO ❑ ) /1 <br /> SURCHARGEAMOUNT FEE CODE .J <br /> RECEIPT# BY: <br /> TITS FORM MUST BE ACCOMPANIFD RV AT 1FASTAAI OR MORE TANK PERMIT FORM `B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> rOHM A(3-2-86) <br /> ^-� 1 <br /> DATA PROCESSING COPY <br />