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STATE OF CALIFORNIA WATER RESOURCES CONTRBOARD <br /> SEF � <br /> r4 -•.,J'a <br /> FORM 'A'. UNDERGROUND STORAGE TANK PROGRAM ~- o <br /> SITEW FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION a <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C��+FORlP <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> A <br /> FACILI /SITt NAME _+,� CARE Of DRESS INFORMATION <br /> L.1 61, U Sri � A d� <br /> ADDRESS NJAR&T CROSS STREET ✓Box to Mute ❑ ARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION iO LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> J �' l '� -•q�ri. ❑ INDMDUAL ❑ COLINTY-AGENCY <br /> CITY NAME STATEZIP'COQ SITE PH NE k,WITH ARE CODE <br /> CA /Q 7J <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID 4 <br /> RESERVATION or #of TANK'S <br /> ❑ 1 GAS STATION [:] 3 FARM ©-POTHER TRUST LANDS El Al AT THIS SITE C <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAY ' NAM (LAST,FIRST) PHONE k WITH AREA CODE DAYS: ME(LAST,FIRST) PHON ti WITH AREA CODE <br /> bg <br /> NIGHTS: J NAME ST, S PHONE 11 WITH AREA CODE NIGHTA'NAME(LAST,FIRST) PHQ N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) drf <br /> NAME CARE OF ADDRESS INFORMATION <br /> 1 <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> _ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE 21P CODE PHONE 9,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME /} � f� � CARE OF ADDRESS INFORMATION <br /> N ylJ U l/"�./ <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 11,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADOAESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 11. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# ` #of TANKS at SITE <br /> M41 1 1 11 E[ I 1 101011 .1 � l _ h I [olOFM <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NA PHONE k WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE lkFltMIT E PIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED ^ <br /> b C YES ElNO� Z <br /> '6 50V <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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) 4 <br /> DATA PROCESSING COPY 0 <br />