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FATE OF CALIFORNIA WATER RESOURCES CONTROL ARD <br /> Ws <br /> ORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM 0 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ;1 <br /> E, COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE •y <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 10 <br /> FACILITY/SITE NAME CARE OF ADORESS INFORMATION <br /> hale ChPdro % " G©, <br /> ADDRESS NEAREST CROSS STREET ✓yRo��to induA 0 PARTNERSHIP Cl STATE AGENCY N <br /> 4.2 3 N• {�Vla�l, S or" F��yr,o n "11I RPORATION El LOCAL AGENCY C3 FEDERAL c" <br /> NON0 IDUAL COUNTYAGENCY <br /> CITY NAME S f STATE ZIP CODE SITE PHO E#,WITH AREA CODE <br /> G K CA �l5 6� CaOC 98-5� <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 P OCESSOR ✓Box it INDIAN EPA ID # A,,, <br /> ❑ I GAS STATION ❑3 FARM 5 OTHER TRUSTRESERVLANDS or ❑ /" V,I e— M of TANK'HIS SI '"� <br /> ATTHISSITE c7( <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 /> Gre am 1i <br /> NIGHTS: NAME( T,FIRST) PHONE p WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> aoq y-7 3- a )" <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME SoCARE OF ADDRESS INFORMATION <br /> me aS sr � e <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME Sa m 'e. a s -e- CARE OF ADDRESS INFORMATION <br /> S % � <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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: I. II. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION# AGENCY R FACILITY ID a a of TANKS a1 SITE <br /> aOal / I (, 1-3 1 10an <br /> CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE a WITH AREA CODE <br /> e a <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION%ODE CEN TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED (y <br /> 3 All YES NO E] -1 ,4 <br /> CHECK a PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT a IBY,. <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 ONLY. <br /> 1 FORM A(3-2-88) <br /> DATA PROCESSING COPY C <br />