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ATE OF CALIFORNIA WATER RESOURCES CONTROARD U w, <br /> ST <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or ERMIT APPLICATION a; <br /> C/ C9lIFOP��P <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> 1 NEW PERMIT ❑ 3 RENEWAL PERMITDin <br /> MARK ONLY ❑ ❑ q AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE - <br /> ONE ITEM ❑ 2 INTERIM PERMIT f 0 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BED COMPLETED) <br /> CARERESS <br /> FACILITY/SITE NAME Lh 1\11( ,L� rV <br /> I NEAREST CROSS ST BEE ✓Baerwej ute [:1PARTNERS8IP Ll STATE AGENCY <br /> ❑ CORPORATON Cl LOCALAGENCYO FfDERA L-AGENCY <br /> ADDRESS ❑ INDIVIDUAL El 6GUNTY AGENCY <br /> c v <br /> 4z STATE ZIP CODE /ITE <br /> EPPHONE N WITH AREA CODE <br /> CITY NAME / CA <br /> EPA ID X Xof TANK's 1� <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑I 4 PROCESSOR /Box if INDIAN <br /> RESERVATION or AT THIS <br /> SITE <br /> ❑ I GAS STATION ❑ 3 FARM TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(SECONDARY) <br /> EMERGENCY CONTACT PERSON(PRIMARY) <br /> FIRST) PHONE <br /> .DAYS'. NAME(IASL FIRST) PHOO�yN1E/X/IWIITHAREACODE DAYS. NAME(LAST. X WITH AREA CODE <br /> EL -)`FEL 3 ' PHONEp WITH AREA CODE <br /> NIGHTS. NAME(LAST.FI T) PHONE 4 WITH AREA CODE NIGHTSNAME(LAST,FIRST) <br /> : <br /> II. PROPERTY OWNER INFORMATION St ADDRESS — (MUST BE CDOMPLLETEoD) <br /> 01 AD <br /> NAME N 0"i u' <br /> ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS ❑ CORPORATION ClLOCAL-AGENCY F1 F ERAL-AGENCY <br /> E INDIVIDUAL ❑ COUNTY-AGENCY (f L <br /> STATE ZIP CODE PHONE q.WITH AREA CODE <br /> CITY NAME <br /> CN I,' <br /> f—+i11 V <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPDLETEDCARE OF RESS IN MAnoN <br /> NA <br /> /� <br /> f'1-(. `-L Box to indicate ❑ PARTNERSHIP ❑ S_T`A�EAGENCV <br /> MAILING or STREET ADDR SS ❑ CORP ORATION ❑ LOCAL-AGENCY ❑ FWERPL(AGENCY <br /> ` ❑ INDIVIDUAL [ICOUNTY-AGENG P <br /> STATE ZIP OD <br /> HONE p.WITH AREA CODE <br /> I Ft �C�-E�/� <br /> CITY NAME IL�LINOI ll � -/1TT v .14 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS V ATIONAND BILLING: I. <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION A ❑ II. III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> FACILITY IDR Xof TANKS et SITE <br /> CO(JU�NT(Y�{JX JURISDICTION X II AGENCY X O O <br /> S17 <br /> WITH AREA CODE <br /> APPROVED BY NAME <br /> CURRENT LOCAL AGENCY FACILITY ID X <br /> ZPERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> PERMIT NUMBER <br /> BUSINESS PLAN FILED DATE FILED <br /> LOCATION CODE CENSUSTRACTX SUPERVISOR-DISTRICT CODE YES NO ElqlB �� O <br /> RECEIPTX BY: <br /> CHECK X PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> 1 FORM A(3-2-88) . 0 S <br /> DATA PROCESSING COPY <br />