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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD SE"` °F . JA <br /> .�.I.� . <br /> r <br /> e 1 n <br /> FORM A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE C1�IFOR�' <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ P TLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CIrOSURE <br /> -J <br /> I.FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) W <br /> CA) <br /> FACILITY/SITE NAMECARE OF ADDRESS INFORMATION <br /> D F s;rpd70A1 _G e <br /> ADDRESS NEAREST CROSS STREET ✓IIo.to ❑ PARTNENSH:P ❑ STATE AGENCY <br /> ❑ COWWTION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> E) INDMDUAL ❑ COUNTY-AGENCY <br /> CITY NAME, STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> S� CA 9S2O?� <br /> TYPE OF BUSINESS: I-1 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> �J RESERVATION or LAT <br /> i TANK s <br /> ❑1 GAS STATION ❑3 FARM ❑5 OTHER TRUST LANDS ❑ THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME ,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> VACt <br /> lCi4 Z4 — a 11 <br /> NIGHTS: NAWE(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME o Is w J CARE OF ADD ESS INrly �^TAA �� �� <br /> MAILING or STREET ADD _`/ Z 11YL W Box to indicate '❑y`ARTNERSHIP ❑ STATE-AGENCY <br /> �J L� �, �i/ Da� ❑ CORPORATION LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> v/ evG� ❑ INDIVIDUAL COUNTY-AGENCY <br /> CITY NAME _ / STAT ZIP CODE � PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS/— (MUST BE COMPLETED) <br /> NAME h C CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 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: 1. IL 111.❑ <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 6 SIGNATURE) DATE <br /> i <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION N AGENCY N FACILITY ID# #o1 TANKS at SITE <br /> 1-171 <br /> -- / 1 -71911 <br /> O o [3 1 <br /> CURRENT LOCAL AGENCY FACT ID 1 APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT• 8UPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> O Z O lJ YES NO -,Ogg <br /> CHECK 1 PERMIT AMOUNT SURCHARGE AMOUNT IL ODE RECEIPT N <br /> THIS FORM BUST 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 \t <br />