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STATE OF CALIFORN WATER RESOURCES CONTROCBOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z <br /> COMPLETE THIS FORM FOR EAC IC <br /> ACILITY/SITE `+�,�op,�> <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 NTLY CLOSED SITE N <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I <br /> I. FACILITY/SITE INFORMATION &ADDRESS — ( U BE COMPLETED) CTI <br /> FACILITY/SITE NAME CA <br /> S MSd/iC>] o/n/ /A/ £ CARE OFADDRESS INFORMATION <br /> V L s <br /> ADDRESS <br /> NEAREST CROSS STREET ✓Bax to rdrtate El PARTNERSHIP El STATE AGENCY <br /> 9 ( OW5 AU NOMDUATElCOCNry ION AGENCY 11FEDERAL AGENCY <br /> CITY NAME AGENCY <br /> STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> 'VAC —CA <br /> Sz3� <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑4 PROCESSOR ✓Bax if INDIAN EPA ID # /J <br /> ❑ I GAS STATION ❑3 FARM ❑ 5 OTHER TRUSTVATION or LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PION WITH APFf CODE DAYS' NAME(LAST FIRST) PHONE#WITH AREA CODE <br /> V- L ?.�9-y6 336 f / ��vN ` 2U9—Y6fi%336 <br /> NIGHTS. NAME(LAST,F ST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIHST <br /> PHONE q WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> 4(/eV CO w N T <br /> MAILING o,ST ET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �i /tea K / ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Y�'` V 1 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP C� PHONE#,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME "-IV YOtIQUlt1 OO` CARE OF ADDRESS INFORMATION <br /> VVP�7 Ll�1LL VV11 [��s/I <br /> MAILING o,STRrEET ADDRESS //��'' ./`.�� ESTATE <br /> ow. ❑ PARTNERSHIP "FEDERAL-AGENCY IIi( SGo 1 e / TION ❑ LOCAL-AGENCYAL ❑ COUNTY-AGENCY <br /> CIN NAME ZIPCOD� � PH3�" <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: 1. ❑ II. ❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# #of TANKS at SITE <br /> d0 _T <br /> 11 3-FIT-41 <br /> D © O <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> OT QL�E ' <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION COD <br /> CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 2 YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> l� <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 /> FORMA(3-2-88) . <br /> DATA PROCESSING COPY 0 S , <br />