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STATE OF CALIFORNIP WATER RESOURCES CONTROL0ARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM °4 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONS rlm.o <br /> rnCOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE s" <br /> 1 0 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAMEL� � CARE OF ADDRESS INFORMATION <br /> `f S I O C f rjyL+ SerL)I Ce C' <br /> ADDRESS NEAREST CROSS STREET ✓e8y�.IO m,pgl¢ ❑ PARTNERSHIP ❑ STATE-AGENCY N <br /> I 1 n1 �n �j �J,, ) �GGRPGRATION ❑ LOCAL ❑ �DEHAL-AGErvcY C,3 <br /> W e S La )i 1 C_ / 1 / ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STgTE ZIP CODE SITE PHONE#,WITH AREA CODE OD <br /> S fo c K ms- CA 5 ,, qw,, -3_,. <br /> TYPE OF BUSINESS'. ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID # <br /> RESERVATION or If of TANK's <br /> ❑ /V - r IXC AT THIS SITE 1 GAS STATION [_] 3 FARM �OTHEA TRUST LANDS 11 <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 /> v''tS ivry 0 erceter C,;loW (05.. �9V7 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> i )/i '%Otiv 0 (JO) '7465 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> pa c i I' C cn a s N- (f e6tr c <br /> MAILING or STREET ADDRESS ✓� oQoxto indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /eyfVCY 0RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> rec' t ❑ INDIVIDUAL E COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Su n Fan <'S In CA <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREETADDRESS %/Box to Indicate ❑ PARTNERSHIP EDSTATE-AGENCY <br /> J'� ❑ CORPORATION ❑ LOCAL-AGENCY [IFEDERAL-AGENCY <br /> �'.� i �' 3 D 11INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE IF CODE PHONE q,WITH AREA CODE <br /> Seo G K+79� C1q q 5 01 K <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. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURREN LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> a <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CEc7STRACT SUPERVISO�TRICT CODE BUSINESS PSN FILED NO ❑ DATE <br /> 11, <br /> CHECKk PERMITAMMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY <br /> `, I 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 /> FORMA(3-2-88) <br /> is DATA PROCESSING COPY • <br />