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STATE OF CALIFORNIT WATER S CONTRO <br /> BOARD <br /> RESOURCES <br /> L r; "— <br /> FORM `A': Asa <br /> UNDERGROUND STORAGE TANK PROGRAM t' <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE cql°FOR�P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION EI'7 PERMANENTLY CLOSED SITE I a <br /> ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 8t ADDRESS — (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME CARE OF ADDR INFORMATIO <br /> rl <br /> ADDRESS NEAREST CROSS STREET v/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 5 0 - ❑ CORPORATION ❑ LOCAL-AGENCY Iy��``DERAL-A NCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY i L/•;SIC, <br /> CITY NAME �,)^ �� STATE ZIP ODE SITE PHONE#,WITH AREA CODE <br /> l �—' CA 3 U9 d3 9 57 9 O <br /> TYPE OF BUSINESS: J'6ISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESE❑ RE <br /> 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLANDS ATION or ❑ #of <br /> AT THHISIS SANK SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> C- CARE OF ADDRESS INFORM)yFIp�/� <br /> ev � P �- .�►� ((UUJJ <br /> MAILING or STREET ADDRESS ) / ✓Box to indicate ElPARTNERSHI 101`STATE-AGENCY <br /> .{-./�� 11C ORATION E] LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> �'�Y ,��'\\\\ NDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STA ZIP CODE PHONE#,WITH AREA CODE <br /> a,fn fe-c�— �- qs i33CU 239 <br /> III. TANK OWNER INFORMATION a ADDRESS— (MUST BE COMPLETED) <br /> NAME _ CARE OF ADDRESS INFORMATION <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 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. ❑ If. 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) _ _—•s— DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 2H I I I J L. 1 I I Lol o I t I q I3 in <br /> CURRENT LOCAL AGENCY FACILITY ID# r APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERM=NUMBER7] PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION cqpf CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED_/G �'`, , <br /> �-4� L YES [j NO ❑ ' - "1 'rD l law <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAS'#§R MORE TANK PERMIT FORM `B'APPLICATION(S), UTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />