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R& WATER RESOURCES CONTI BOARD <br /> STATE OF CALIFO <br /> V 1 m <br /> FORM `A': UNDERGROUND STORAGE TA K PROGRAM Yeo z. <br /> SITE FACILITY/SITE, INFORMATION and/or ERMIT APPLICATION �q� Fo P <br /> 'lJ COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00 <br /> 00 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITYISITE NAME CARE OF ADDRESS INFORMATION <br /> cle ADDRESS [ NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ' 1 J V<<+- ,- a f�/7 y p j,�. ❑ CORPORATION ❑ LOCAL-AGENC! ❑ FEDERAL-AGENCY <br /> L/'/1�! � I r(ft�I �l-7 ❑ INOIYI011AL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> TY�OESINEWS: ❑ 2 DISTRIBUTOR ❑ 4 PRDCE&%R ✓Box ii INDIAN EPA ID # #of TANK's <br /> ❑ 5 OERESERVATION or ❑ AT THIS SITE <br /> STATIDN ❑3 FARM TRUST LANDS <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 /> Et,C1,Cj-L Ecl aq) 4&3- 0(0&-/ Er�d%cit Kzrc <br /> NIGHTS: NAME{LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> �,r1 Chi[.f2, teras <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ,.�),"f�` [I CORPORATION C1LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Lf/ / lU[. ❑ INDIVIDUAL ❑ COUNTY-AGENCY <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 /> nd i chd /3roS <br /> MAILING or STREET ADDRESS f %/Box to indicate Q PARTNERSHIP C1 STATE-AGENCY LVr�Y!�� � <br /> C] CORPORATION C1LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL El COUNTY-AGENCY <br /> CITY NAME STATE Zlp CODE P E#,WITH AREA CODE <br /> C""? -(9667 <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. ElII. ❑ I11. ❑ <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# a( FACILITY ID# #of TANKS attSITE <br /> v � �/ <br /> 1 010 T � <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA COPE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS QT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FWINFORMATION <br /> r QQIJO 3 res No <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT#THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SIT <br /> q FORM A(3-2-88) <br /> I� !�� DATA PROCESSING COPY <br />