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STATE OF CALIFORN._4 WATER RESOURCES CONTh_-' BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 6 <br /> ew COMPLETE THIS FORM FOR EACH FACILITY/SITE �'�q(rFORN P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q' ' <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) o <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> f aC ►:-��' L AF ry <br /> ADDRESS PRrIIW(SS STREET ,,✓ windicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> / / �4 C Z` C� 1Q LSTCORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> T V` Ir v e ❑ INDIVIDUAL ❑ COUNTY-AGENCY -4 <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> S�o C. c.'-n- CA A o 7 0`l y5d. - 151? <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID # <br /> RESERVATION or , #of TANK'S <br /> / lGAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ U v C_ 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 /> d61v9 15�-65Y I <br /> NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> o m e- A09 <br /> 11. (PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME ^�1 G Q I CARE OF ADDRESS INFORMATION <br /> MAILINGor STREET ADDRESS �7 �✓B�to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �, ht 3 �/ JC EL ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> lVJ 0 /\ 1J ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> iii9-n a, hc/'4 3 qz� a 3 <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SQ'YY1 e— Q S a 0 o F <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. X 11. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> [Jjj] 1 1 T] I I I I L 0 1 OF�� <br /> CURRENT,LOCAL AGENCY FACILITY ID# APPR VE BY NAME PHONE#WITH AREA CODE <br /> PL, <br /> PERMIT NUMBER PERMIT APPR VAL DATE PERMIT EXPIRATION DATE <br /> a? a a <br /> LOCATION CODE CENSUS TRACT# I SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 31 �D / J YES ❑ NO ❑ 71, 0 {se <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# B <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 /> fY <br /> DATA PROCESSING COPY J <br />