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STATE OF CALIFORNO WATER RESOURCES CONTROBOARD <br /> Sx� f <br /> �I A <br /> 1 f <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM = PR by <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 6I —4 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 'A <br /> .A <br /> FACILITY/SITE NAME XfI K(( T �' CARE OF ADDRESS INFORMATION <br /> eN KA i <br /> ADDRESS NEAREST CROSS STREET ✓Bar to in4mW Cl PARTNERSHIP ElSTATE AGENCY <br /> VPoRALION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> `J.U l3 'f (6 P / A� lvlouAL ❑ COUNT AGENOr <br /> CITU NAME 1 `A ON STATE <br /> -33C ZX CODE EPHO WITH AREA�2 <br /> A 38' <br /> F-1F__]TYPE OF BUSINES : 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA IID N YIf <br /> RESERVATION or AT TANK'N <br /> ❑ 1 GASSTATION V 3 FARM E:] 5 OTHER TRUST LANDS ❑ AT THIS SITE / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(I-AST,FIRST) PHONE N WITH AREA CODE <br /> Kew <e Nj 1- '2_09 s99-z23e <br /> NIGHTS: NAME 1-A T,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> t—wN ✓ J -204 -Gig-22381 <br /> IL PROPERT OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> e <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION Cl LOCALAGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. ❑ IN. ❑ <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 N FACILITY IDN N of TANKS at SITE <br /> = = = I I I 9101 38 <br /> CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE N WITH AREA CODE <br /> QLAJNsgo <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION LODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI D <br /> .L Z 32� YES NO gllql <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 IB'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> �� 1 0 DATA PROCESSING COPY <br />