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y'�OF T... <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL1ARD <br /> rA <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM 'lo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONJoi . , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> F <br /> ARK ONLY ❑ 1 NEW PERMIT F—] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANEN L D SITENE ITEM ❑ 2 INTERIM PERMIT El AMENDED PERMIT El TEMPORARY SITE CLOSURE �� "J <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W <br /> FACILITY/ ITE NAMEl� S CARE OF ADDRESS INFORMATION <br /> rl�u.�c � �co - .d. . <br /> I A./ <br /> ADDRESS NE R ST CR STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ��'r j/� / / ❑ CORPORATION ❑ LOCAL-AGENCY EARL-A NCY <br /> [✓ 6. V G�C!/� s ❑ INDIVIDUAL ❑ COUNTY-AGENCY iie <br /> CITY NAME STATE ZIP OD SITE PH NE#,WITH AREA CODE <br /> �6 �r <br /> A <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4 LESSOR ✓Box if INDIAN EPA ID # <br /> 11[7 ' <br /> RESERVATION or #of TANK's �,) <br /> ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE 0 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> RL�Z4&ml <br /> SPHONE#WITH AREA CODE DAYS AME(LAST,FIRST) PHO # ITH AREA CODE <br /> SIA <br /> NIGHTS: NAME(LAST, IRST) P ONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE <br /> IfA 4 s � <br /> s � <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> N � CAREOF PDRESS INFORMATION <br /> MAILIN r STREET R S ✓Box to indicate EI PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ElLOCAL-AGENCYEDERA AG NCY <br /> 11' ,�i✓ c 1116 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME. _ STATF CA ZIPS ! PHI ITH AREA CODE <br /> LA <br /> III. TANK OWNER INFORMATION &ADDRESS_— (MUST BE COMPLETED) <br /> NAME ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ox to indicate El PARTNERSHIP ElSTATE-AGENCY <br /> �� ;ORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY <br /> VDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME /` fl ZIP CODE PHONE#,WITH AREA CODE <br /> cef <br /> IV. LEGAL NOTIFICATION AND BI <br /> CHECK ONE(1)BOX INDICATING WHICH ABO EGAL NOTIFICATION AND BILLING: I. ❑ If. III. ❑ <br /> THIS FORM HAS BEEN COMPLETED O THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIC DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY ID# #of TANKS at SITE <br /> D d <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NA E PHONE#WITH AREA CODE <br /> ,4N -­'aI-I--- m&. 51 R <br /> IF I <br /> PERMIT NUMBER PERMIT APPROVAL DATE 6ERMIT EXPIRATION DATE <br /> LOC /, <br /> ATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> L-- 2-3-?6 <br /> `?-86 I YES ❑ NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT TFEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FjORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br /> I <br />