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STATE OF CALIFORNIP WATER RESOURCESCONTROLBOARD <br /> 4 f <br /> W \i <br /> FORM `A'N ' <br /> UNbERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION l o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> FMARK ONLY ❑ 1 NEW PERMIT F—] 3 RENEWAL PERMIT ❑ 5 CHANGE OFINFORMATION 7 PERMANENTLY CLOSED SITE F"#' <br /> ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE4 00 <br /> V" <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) a <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION - <br /> n r hsef-n S( I E c, I i SAY <br /> ADDRESS _ NEAREST CROSS STREET ✓¢e+ induce ❑ PARTNERSHIP ❑ STATE AGENCY <br /> n</o �. Q 1 a1_ 1 v 'T - �COAPOAAiION ❑ LOCAL ❑ FEDERAL <br /> (((///) O b L d-- MODAL ❑ COUNTY AGENCY <br /> CITYNAM STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> C _ ' bn CA LA&1c_ <br /> TYPE OF BUSINESS. ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Bax if INDIAN EPA ID # <br /> If Of TANK'e <br /> ❑ 1 GAS STATION ❑ 3 FARM THER TRUSTVLANDS TATION RUST LANDS <br /> ❑ ATTHIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAY(�NAME(LAST,XEST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 1JQu-,z_ L56rft&x _10-1 a5459s33 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> y 15 5;0 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME � _ In vrocylb hoo <br /> cc, <br /> CAREOFADDRESS INF�lMATION <br /> MAILINGmS REET ADDRESS I <br /> o ✓8ox lomdicale ❑ PARTNERSHIP LlSTATE-AGENCY <br /> l l ❑ INDIVIDUAL ❑ COUNTY-AGENCY LlFEDERAL-AGENCY <br /> CITY NAK 1 STA ZIP CODE PHONE#,WITH AREA CODE <br /> I`-YI` � <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME1u _ u, CARE OF ADDRESS NFOR <br /> MAILING o STR ETADORESS ✓ indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> (� O_� CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> v A1�LC/� ILLS ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME C//1 STAT Z70D PRONE 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. ❑ if. V 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 B SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# Of of TANKS at SITE <br /> 3n o <br /> CURRENT L�;LLAAGENCY FACILI�# APPROVED BY NAME PHONE Or WITH AREA CODE <br /> PERMIT NUMBER HH U PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> z <br /> LOCATION CO1 E CENSUS TRACT III SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> l a � YES NO ❑ LO I I � <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 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) L, (�\� <br /> DATA PROCESSING COPY <br />