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.. r: <br /> lzF;�'`iupi+r� r�F <br /> STATE OF CALIFORNIO WATER RESOURCES CONTR BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM F� � Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C4LIFoR <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> 5 CHANGE OF INFORMATION (CLOSED SITE <br /> 1 NEN!PERMIT � S RENEWAL PERMIT � <br /> MARK ONLY 6 TEMPORARY SITE CLOSURE F� <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT <br /> IV <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BEGCOM COMPLETED) <br /> CARERESS NATION <br /> FACILITYlSITE NAME - + � �,. <br /> NEAREST CROSS STREET ✓Bortonddte ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> n�, J� ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEOERAL-AGENC'I <br /> ADDRESS r `mow /�'{ '�i1C..15T Cl INDIVIDUAL Q C(fNNTY-AGENCY <br /> V Y' STATE Z'�C'O�E_ � � SITE PHONE p,WITH AREA GOD© <br /> CITY NAME / CA <br /> EPA ID n #of TANK's <br /> TYPE OF USINESS: M 2 DISTRIBUTOR 4 PROCESSOR Box ii TION o <br /> RESERVATION or n AT THIS SITE <br /> 1 GASSTATION 0 3 FARM 5 OTHER TRUST LANDS 1� <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECOIll NDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE#WI�TA1Hy/Ary`REA CODE DAYS. ME(LAST,FIRST} //' <br /> PHONE#WITH AREA CODE <br /> L yv ` 7 ref ljF PHONE Or WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRSI)IIIPHONE It WITH AREA CODE NIGHTSNAME(LAtT.FIRST <br /> 11. PROPERTY O NER INFORMATION & ADDRESS — (MUST BE CO PLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> G ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS r Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> fl INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE _ ,� YIP CODENiTH AREA GOD <br /> CITY NAME C�/ly ,�] wiz) <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED <br /> CARE OF ADDRESS INFORM) <br /> ATION <br /> OMLETEFO,ATION <br /> NAME a ^ { <br /> ✓Eiax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS . ❑ CORPORATION ❑ LOGAL-AGENCY ❑ FEDERAL-AGENCY <br /> + ❑ INDIVIDUAL El COUNTY-AGENCY H AREA CODE <br /> STATE ZI PHONE q, 3--d , ` <br /> CITY NAME ,q _ _ 4f�.'�h <br /> 57 <br /> IV, LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE{7}BOX INDICATING WEl <br /> HICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. it. 111' <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY #of TANKS at SITE <br /> COUNTY# JURISDICTION# <br /> AGENCY# FACILITY ID# <br /> Zlz <br /> APPROVED BY <br /> NAME PHONE K WITH AREA CODE <br /> CURRENT LOCAL AGENCY FACILITY ID# <br /> PERMIT HUMBER <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> BUSINESS PLAN FILED DATE FILED <br /> SUPERVI$OR-DISTRICT CODE NO <br /> LOCATION CORE CENURACT _ YES <br /> Ol��' CfJ(v RECEIPT# BY: <br /> / SURCHARGE AMOUNT FEE CODE <br /> CHECK# PERMIT AMOUNT <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1}OR MORE TANK PERMIT FORM `B'APPLICATION{S}, UNLESS THIS ISA CHANGE 4�SVTEINFORMATION OLS. <br /> 9� FORMA(8-2-68} 0 <br /> DATA PROCESSING COPY <br />