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STATE OF CALIFORNIP WATER RESOURCES CONTRIMOARD <br /> FORM `A': 4� s, <br /> UNDERGROUND STORAGE TANK PROGRAM =" o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , 10 <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION P/ TLY CLOSED SITE (� <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT 1:16 TEMPORARY SITE CLOSURE ,b <br /> cn <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W <br /> IV <br /> FACILITY/SITE NAME /� CARE OF DRESS INFORMA I N <br /> atiN/S COu cc�ioN a�rN <br /> ADDRESS NEARRESS]'CRESS REET ✓Bor.lo iW ore ❑ PARTNERSHIP Cl FATEAGENCY <br /> "RALOCAL AGENCY 11 <br /> ❑ IHDAVI0UALION 0 COUNTYAGENGY FEDERAL AGENCi <br /> CITY NAMESTATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> Wi4ecrti CA 75936 <br /> TYPE OF BUSINESS. ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a #of TANK'a <br /> ❑ ❑ TTRUSTYLANDS A ION or ❑ <br /> I GAS STATION 3FAAM SOTHER —TAT SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(IAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST FI ST) PHONE N WITH AREA CODE <br /> ull,� 20 3 p -? z� kN / n oNC'_ <br /> NIGHTS: NAMF'.A— nesTl / PHDNt a WITH AREA CODE NIGHTS: NAM (LAST,FIRt) PHONE 4 WITH AREA CODE <br /> dt L 4 _Z37 <br /> 3 — <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME S-ame os CARE OF ADDRESS INFORMATION <br /> � <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION Cl LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> us <br /> MAILING or STREET ADDRESSvoxmindicate 1-1PARTNERSHIP ElSTATE-AGENCY <br /> CORPORATION Cl LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE ft,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: 1.9 <br /> . if. ❑ 111.❑ <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 R AGENCY R FACILITY ID N N of TANKS at SITE <br /> 1,0101 / 1115111 <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE M WITH AREA CODE <br /> ff Ns7 ►jh <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK# <br /> CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILE <br /> 2, !Eo � YES E NO I C— <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> \ 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 ONL� <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY 0 __� <br />