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STATE OF CALIFORNff WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> (� COMPLETE THIS FORM FOR EACH FA LITY/SITE <br /> FMARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C SED SI z <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 6/ #Q <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Dov 0 PARTNERSHIP 0 STATEAGENCY V• <br /> � /_ l <br /> Cl CORPORATION 11 LOCAL r1GEND ElEEDEAAL.IGENCY <br /> / i ll;t e hJ cAe 1kt01 C/ /4cc.e I ❑ INDIVIDUAL ❑ COUNtt_ACENa <br /> CITY NAME STATE ZIP CODE SITE PHONE If,WITH AREA COOS <br /> f5calo. CA <br /> %S3 )J #2 63Y-3 U <br /> TYPE OF BUSINESS. ❑ 2 IRIBUTOR ❑ 4 PROCESSOR ✓BOX iI INDIAN EPA ID # <br /> RESERVATIONor #of TANK'# <br /> ❑ 1 GA$STATION 3 FARM E] 5 OTHER TRUST LANDS ❑ urt AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> ,Fer 6�:>` - -3 u sa <br /> NIGHTS. NAM€(LAST FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ._S aeAl2 SG[W-f <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> %-hove If <br /> MAILING or STREET ADDRESS ,,✓Boxx O'Odicate ❑ PARTNERSHIP 0 STATE AGENCY <br /> El yORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> INDIVIDUAL Cl COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> /71`JO✓e- <br /> / <br /> MAILING or STREET ADDRESS I/Box loiodicale Cl PARTNERSHIP 0 STATE-AGENCY <br /> INDRPORATION 11 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> IVIDUAL ❑ 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. if. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY IDN If of TANKS at SITE <br /> 110 6 lo 1,2 ] <br /> RRENT LOCAL AGENCY FACILITY ID# APPROVE PHONE#WITH AREA CODE <br /> PE BER PERMIT APPROVALAMCIIE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> a 3d-12 3 a42 YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: CIA 0 <br /> 1 I THIS FORM MUST BE ACCOMPANIED BY AT LE OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) `'LA��_ - <br /> '\ DATA PROCESSING COPY _7 <br />