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Y, `jTIwr.AT *., �-.,. .-..,. r. •g Si:t: <br /> —o� <br /> STATE OF CALIFORA WATER RESOURCES CONTSBOARD � ""`"'' `� <br /> W: <br /> x <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM RLa <br /> S17_,E FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> _ COMPLETE THIS FORM FOR EACH ACILITY/SITE _"-"P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Fer5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE " <br /> 10 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ir <br /> s V 2.C` N <br /> ADDRESSNEAREST CROSS STREET ✓Boa to intlicale [I PARTNERSHIP ❑ STATE AGENCY 00// c. ❑ CORPORATION [ILOGALAGENCY El FEDERAL AGENCY <br /> T 0 o 15Mai n Sa <br /> S+, t-f er ❑ INDIVIDUAL ❑ COUNTVAGENCY 00 <br /> CITY NAME STATE ZIP CODE SITE PHONE 4,WITH AREA CODE <br /> CA Jt a a- NmT e <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID 4 It of TANK'sRESE / <br /> ❑ 1 GASSTATION ❑ 3FARM 9.fOTHFR TTRUSTYLATION ANDSo ❑ Aii AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. N ME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE4 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> e S d" ss <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY. a 5 ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITU NAME He <br /> ^ STATE ZIP CODE PHONE 4,WITH AREA CODE <br /> /` L / <br /> III. TANK OWNER IN ORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAMECA OF ADDRESS INFORMATION <br /> e fiti a4, Sa Vi -5 1 ifl I � <br /> MAILINGOJT ET ADDRESS MY Box to Indicate LI PARTNERSHIP ❑ STATE e-r -AGENCY <br /> �.//. Ll CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY <br /> / a ❑ INDIVIDUAL [ICOUNTY-AGENCY <br /> CITY NAME STATE ZIP DDE PHONE p,WITH AREA CODE <br /> C d <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- ❑ it. ❑ 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 N JURISDICTION N AGENCY# FACILITY ID F a of TANKS at SITE <br /> a9 = = 101011106131ODoI <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMI NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS YPELSAN FILED NO ❑ <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k 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 ONLY.5 <br /> FORMA(3-2-88) � J\ <br /> DATA PROCESSING COPY <br />