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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or P RMIT APPLICATION ° to <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I`+ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O <br /> 1. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> (D <br /> FACILITY/SITE NAM` CARE OF ADDRESS INFORMATION <br /> M U7 �W <br /> ADDRESS � NEAREST CROSS STREET ✓ min,om ❑ PARIMIRSM ❑ UATEAGM <br /> /!/ry�0 S, /AMONo COLP ort Da Cl LOCAL4WO ❑ FEM AGENCY <br /> MWIDUAL 1:1 CUM Amicy <br /> CITY NAME STATCZI OLFy� SITE PHONE II,WITH AREA CODE <br /> A <br /> TYPEOFSUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR -/Box if INDIAN EPA IDN <br /> ❑ I GASSTATION ❑ 3 FARM ❑ 5OTHER RESERVATION or ElRof TANK'R <br /> TRUST LANDSAT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST n A PHONE N WITH AREA CODE <br /> /c Zoy 67-6coo orc z /�f <br /> NIGHTS: NAME LAIRT,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ewri <br /> MAILING or STREET ADDRESS x to indicate Cl PARTNERSHIP ❑ STATE AGENCY <br /> Y O O ( CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE� � ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ox to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOA INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 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 R JURISDICTION M AGENCY R FACILITY ID M R of TANKS at SITE <br /> Ov 8 Id 60 7 <br /> CURRENT LOCAL AGENCY FACILITY ID� F APPROVED BY NAME PHONE R WITH AREA CODE <br /> A M0 <br /> ID <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> is z 88' I <br /> LOCATION CODE CENSUS TRACT R SUPERVISOR-DIS"jo CODIF BUSINESS PLAN FILED DATE FILED <br /> YES NO E]CHECK♦ <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTR BY: <br /> xx <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 /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />