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STATE OF CALIFORNO WATER RESOURCES CONTROBOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> E <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE O'ER �# <br /> MARK ONLY ❑ i NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED 517E FJ <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE N <br /> 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME II CARE OF ADDRESS INFORMATION Ln <br /> T \ CIS I >�. &k- <br /> ADDRESS NEA ST CROSS STREET ✓BoC ilgicae El PARTNERSHIP Cl STATE AGENCY <br /> C( CYC o_� �j luc� w�& ❑ INrRPonATION ClAGIlAI LOCAL AGENCY <br /> 11IEDERA(AGM <br /> CITY NAME COUNTI <br /> STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> rnca <ta c CA g533(P 209 <br /> TYPE OF BUSINESS: ❑p OISTgIBUTOq ❑ 4 PROCESSOR Box if INDIAN EPA 1D k <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHEq RESETRUSTMLANDS or ❑ #of TANK'# <br /> .--�� AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) (� PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 0q`&1.31)LP`G <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 /> NA7" CARE OF ADDRESS INFORMATION <br /> I I 'N UCL'�. .1Lt.SL�t Y\ S 1 <br /> MAI .IIIrSTREETADDRESS !650x to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> pI CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> �J U�'1 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> d vwA c��- <br /> MAILING or STREET ADDRESS ✓Bax W indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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: 1. ❑ II. I. ❑ <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 /> C <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> ® 16 U <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> M c� TE 9 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT II SUPERVISOR-DISTRICT CODE BUSINESS!PLAN!F!lLEO NO ❑ <br /> 13 70 1 <br /> CHECL/K��# PERMIT AMOUNT SURCHA'RRGGEE AMOUNT FEE CODE RECEIPT# (IBY: <br /> \ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />\\v\N\ FORM A(3-2-88) • 0 <br /> DATA PROCESSING COPY <br />